HEALTH  SCIENCES  STANDARD 


HX00038636 


M^IOI 


Columbia  (Bnttierstttp 

COLLEGE  OF 

PHYSICIANS  AND  SURGEONS 

LIBRARY 


MEDICAL   GYNECOLOGY 


MEDICAL    GYNECOLOGY 


BY 

HOWARD  A  KELLY,  A.B.,  M.D.,  LLD.,  F.R.C.S.  (Hon.  Edinb.) 

PROFESSOR  OP  GYNECOLOGICAL  SURGERY  IN  THE   JOHNS   HOPKINS   UNIVERSITY,   AND    GYNECOLOGIST  TO    THE  JOHNS 
HOPKINS   HOSPITAL,    BALTIMORE  ;    FELLOW  OF   THE   AMERICAN   GYNECOLOGICAL   SOCIETY  ,"    HONORARY   FELLOW   OP 
THE    EDINBURGH    OBSTETRICAL    SOCIETY  ;    HONORARY    FELLOW    ROYAL    ACADEMY    OP    MEDICINE    IN    IRELAND  ; 
FELLOW    BRITISH    GYNECOLOGICAL    SOCIETY  ;     HONORARY    FELLOW    GLASGOW    OBSTETRICAL    AND    GYNECO- 
LOGICAL   SOCIETY  ;     HONORARY   MEMBER   OF    THE    ROYAL    MEDICAL    SOCIETY   OF    EDINBURGH  ;    CORRE- 
SPONDIRENDBS     LND     EHRENMITGLIED     DER     GESELLSCHAFT     fOr     GEBURTSHULFE     ZU     LEIPZIG  ; 
EHRENMITGLIED   DER    GESELLSCHAFT   FOR   GEBURTSHCLFE     U.  GYN.  ZU   BERLIN  ;    CORRESPON- 
DIRENDES   MITGLIED   DER   K.  K.  GESELLSCHAFT    DER   AERZTE    IN   WIEN  ;    MEMBRE   ASSOCIE 
ETRANGER,  SOCIETfi  D'OBSTETRIQUE,  DE   GYNficOLOGIE   ET    DE   PKDIATRIE   DE   PARIS  ; 
MEMBRE   CORRESPONDANT    fiTRANGER   DE   LA   SOClfiTE    DE   CHIRURGIE    DE    PARIS  ; 
MEMBRE     DE     L'ASSOCIATION     PRAN9AISE     D'UROLOGIE,     PARTS  ;     MEM.     HON. 
SOCIETI  ITALIANA  DI  OSTETRICIA  E  GINECOLOGIA,   ROME,   ETC.,   ETC. 


WITH  ONE   HUNDRED  AND   SIXTY-FIVE  ILLUSTRATIONS 

FOR  THE  MOST  PART  BY  MAX  BROEDEL  AND  A.  HORN 


SECOND    EDITION 


NEW   YORK    AND    LONDON 

D.    APPLETON     AND    COMPANY 

1912 


CoPYKiGHT,  1908,  1909,  1912,  by 
D.    APPLETOX    AND    COMPANY 


PRINTED   AT   THE   APPLETOX   PEESS 
NEW   YORK,    V.    S.    A. 


H/2. 


TO  THE  IDEAL  GENERAL  PRACTITIONER,  A 
MAN  OP  WIDE  CULTURE  IN  HIS  PROFESSION, 
IN  CLOSE  TOUCH  WITH  ALL  THE  SPECIAL- 
TIBS,  THE  BELOVED  FRIEND  OF  HIS  PATIENTS, 
AND  ABOVE  ALL,  IN  EVERY  RELATION  OF 
LIFE   A   SINCERE   AND  A   DEVOUT   CHRISTIAN  : 

TO 

Dr.   BRICE   W.   GOLDSBOROUGH 

this  book  is 

affectionately  dedicated 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicalgynecologOOkell 


PEEFACE  TO   SECOND  EDITION 


I  AM  glad  that  a  second  edition  of  Medical  Gynecology  has  been  called  for 
and  I  trust  that  it  will  be  as  kindly  received  as  the  first.  In  order  to  make  the 
book  more  useful  to  the  general  practitioner  I  have  added  a  chapter  on  Diseases 
of  Advanced  Age,  and  I  have  extended  the  brief  account  of  the  Menopause 
considerably.  Dr.  Curtis  F.  Burnam  has  written  the  paragraphs  on  Salvarsan, 
as  well  as  those  on  Radiotherapy  and  Radiography ;  in  the  use  of  radium  his 
experience  has  been  unusually  large.  Several  new  illustrations  have  been  added 
and  the  whole  of  the  volume  has  been  carefully  re-edited  by  those  who  helped 
me  prepare  the  first  edition.  My  great  desire  throughout  has  been  to  do  some- 
thing to  serve  the  general  practitioners  of  the  country,  among  whom  I  have  so 
many  very  close  friends. 

Howard  A.  Kelly. 


PREFACE. 


What  a  transformation  two  generations  have  witnessed  in  the  field  of 
gynecology !  From  modest  beginnings,  as  a  sort  of  a  minor  specialty  coupled 
with  diseases  of  children  and  often  professed  by  general  practitioners  with  no 
special  training,  it  has  grow^n  to  the  dignity  of  a  major  surgical  specialty,  so 
extensive  that  many  gynecologists  of  to-day  claim  the  entire  field  of  abdom- 
inal surgery  as  their  proper  domain  by  right  of  discovery  and  conquest.  This 
period  of  surgical  evolution  is  now  at  last  clearly  at  an  end  and  I  deem  it  a 
fitting  time  to  review  once  more,  from  our  new  and  advanced  standpoint,  the 
relationship  of  our  specialty  to  the  field  of  general  practice. 

To  my  mind  the  evolution  of  scientific  medicine  must  ever  run  this  course : 
The  general  practitioner  yields  up  to  a  little  group  of  investigators  that  por- 
tion of  his  territory  which  is  most  obscure  and  difficult,  in  which  he  has  made 
the  least  progress;  the  field  is  diligently  cultivated  and  a  specialty  is  formed. 
Then  in  time  the  specialist  so  simplifies  the  etiology,  the  diagnosis,  and  the 
treatment,  that  he  is  able  to  hand  back  a  part  at  least  to  the  general  practi- 
tioner, with  whom  he  continues  in  relations  of  harmony  and  sympathy,  so  that 
both  work  conjointly  to  a  common  end,  namely,  the  extinction  of  disease  and 
the  amelioration  of  its  ravages.  It  will  be  my  effort  in  the  following  pages  to 
review  my  special  field,  in  an  endeavor  to  return  to  the  general  practitioner 
that  portion  of  it  which  he  ought  to  recover  by  right  of  his  prior  lien. 

Two  subjects  stand  out  preeminently  as  the  field  of  the  practitioner  of 
medicine,  namely,  hygiene  and  prophylaxis.  He  also  sees  and  is  often  per- 
plexed by  the  sequelae  of  the  various  gynecological  operations.  A  variety  of 
minor  operations  he  must  often  be  prepared  to  do,  notably,  suture  of  the 
recently  torn  perineum,  dilatation  and  curettage  of  the  uterus,  etc.  Largely 
in  his  hands  also  lies  the  fate  of  the  great  army  of  cancer  patients,  wdio  to-day 
apply  to  the  specialist,  as  a  rule,  too  late  for  relief. 

I  have  often  heard  the  cry  ne  sutor  ultra  crepidam,  during  the  twenty- 
five  years  I  have  been  practising  medicine,  but  it  has  not  seemed  to  me  to  be 
trespassing  too  far  on  other  fields  to  take  up  such  every-day  topics  as  hysteria 
and  its  allies,  headache,  backache,  and  constipation. 

I  am  indebted  to  the  kind  cooperation  of  my  friend  and  colleague  Dr. 
Lewellys  E.   Barker  for  the  chapter  on  neurasthenia,  hysteria,  and  psychas- 


X  PKEFACE. 

tlienia.  Tliis  chapter  offers  tlie  first  explicit  and  detailed  statement  which 
Professor  Barker  has  as  yet  made  touching  his  methods  of  dealing  with  this 
class  of  cases.  It  constitutes  a  most  difficult  branch  of  therapeutics  with  which 
his  name  is  associated  as  a  pioneer,  and  I  am  thankful  to  have  this  definite 
expression  of  ideas  from  such  an  authority  upon  a  suljject  in  regard  to  which 
the  gynecologist  so  often  stands  in  need  of  the  advice  of  an  expert  neurol- 
ogist. Dr.  Lilian  Welsh,  Professor  of  Physiology  in  the  Woman's  College 
of  Baltimore,  and  Dr.  Mary  Sherwood,  Director  of  the  Gymnasium  at  the 
Brvn  Mawr  School,  have  written  the  chapter  on  the  hygiene  of  the  growing 
girl,  dealing  with  the  most  fundamental  question  of  our  work.  My  old  friend 
Dr.  Walter  L.  Burrage  has  written  the  chapter  on  gonorrhea  as  well  as  that 
on  fibroid  tumors  of  the  uterus.  Dr.  Prince  A.  Morrow,  our  great  American 
authority  on  venereal  disease,  has  supplied  that  on  syphilis ;  and  abortion 
comes  from  the  pen  of  Dr.  Edward  J.  111.  The  section  on  movable  kidney  is 
by  Dr.  P.  "VT.  Griffith;  enteroptosis  is  by  Dr.  Thomas  P.  Brown  and  mastur- 
bation by  Dr.  P.  L.  Dickinson. 

The  book  has  been  fostered  from  its  incipiency  by  my  friend  and  co-laborer, 
Dr.  Caroline  Latimer,  without  whose  aid  it  could  not  have  been  written.  She 
has  nursed  it  throughout  with  unwonted  solicitude  and  after  revision  and  cor- 
rection sent  it  forth  into  the  world  to  battle  for  a  living. 

I  am  indebted  for  help  and  suggestion  to  Dr.  W.  L.  Burrage  and  Dr.  C.  P. 
Burnani  through  a  large  part  of  the  book ;  to  Dr.  T.  R.  Brown  in  the  chapter 
on  constipation,  headache,  insomnia,  and  obesity;  to  Dr.  G.  W.  Dobbin,  Dr. 
Pichard  Xorris,  and  Dr.  J.  M.  Slemmons  in  the  chapter  on  injuries  and  ail- 
ments after  labor.  Dr.  TT.  S.  Baer  has  given  me  valuable  advice  concerning 
the  treatment  of  backache,  in  which  chapter  I  draw  special  attention  to  sacro- 
iliac disease,  and  Dr.  G.  L.  Hunner  has  assisted  me  in  revising  the  chapter 
on  cancer. 

The  illustrations,  one  hundred  and  sixty-three  in  number,  have  almost  all 
been  made  by  Messrs.  M.  Brodel  and  A.  Horn,  my  longtime  faithful  coad- 
jutors. In  many  of  them  we  have  worked  on  comparatively  new  lines,  securing 
a  more  realistic  and  greater  artistic  effect  in  certain  cases  where  it  was  formerly 
necessary  to  rely  solely  upon  diagrammatic  representation.  Such  illustrations 
are  line  drawings  of  examinations,  postures,  methods  of  treatment,  and  others 
which  will  be  readily  recognized  from  their  generic  resemblance. 

HowAED  A.  Kelly. 


CONTENTS 


CHAPTER  PAGE 

I.  Consulting  Room  and  Appointments.     Gynecological  Examination    .        .  1 

II.     Hygiene  of  Infancy  and  Girlhood 40 

III.  Normal  Menstruation.     Menopause 78 

IV.  Dysmenorrhea.     Dilatation.     Membranous   Dysmenorrhea    ....  105 
V.     Intermenstrual  Pain 132 

VI.    Amenorrhea.     Vicarious  Menstruation 140 

VII.  Menorrhagia  and  Metrorrhagia.     Extra-uterine  Pregnancy         .        .        .163 

VIII.     Constipation.     Headache.     Insomnia.     Obesity 207 

IX.     Backache.     Coccygodynia 250 

X.  Acute  Infectious  Diseases  as  a  Cause  of  Pelvic  Disease   ....  265 

XI.     Vaginitis.     Vulvitis.     Cervicitis.     Endometritis 275 

XII.  Pruritus.     Vaginismus.     Masturbation         .        .        .        .        .        .        .        .  295 

XIII.  Displacements  of  the  Uterus 317 

XIV.  Pelvic  Inflammatory  Disease 335 

XV.     Sterility 346 

XVI.     Gonorrheal    Infection          375 

XVII.     Syphilis 392 

XVIII.     Abortion 452 

XIX.     Injuries  and  Ailments  following  Labor 477 

XX.     Fibroid  Tumors 488 

XXI.     Carcinoma.     Diagnosis  and  Palliative  Treatment 513 

XXII.     Cystitis 543 

XXIII.  Functional  Nervous  Diseases  Met  with  by  the  Gynecologist    .        .        .  565 

XXIV.  Appendicitis  in  Association  with  Pelvic  Disease 586 

XXV.     Splanchnoptosis.     Movable   Kidney 597 

XXVI.     Post-Operative   Conditions 622 

XXVII.     Diseases  of  Advanced  Age 635 

xi   ' 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  A  simple  form  of  consulting  and  reception  room 2 

2.  Arrangement  with  examining  room  separated  from  consulting  room      ....  2 

3.  The  gynecological  examining  table 7 

4.  Piezometer  used  to  register  the  depth  and  amount  of  abdominal  pressure  made          .  8 

5.  Deviation  of  the  sigmoid  flexure 9 

6.  Bimanual  examination  by  vagina  and  abdomen 10 

7.  Bimanual  examination  of  the  uterus 11 

8.  Bimanual  examination  of  pelvic  organs  by  rectum  and  abdomen 12 

9.  Trimanual  examination .  13 

10.  Bimanual  examination  showing  the  method  of  palpating  a  fibroid  tumor     ...  14 

11.  Bimanual  examination  showing  the  method  of  detecting  an  ovarian  tumor          .        .  14 

12.  Outlining  the  enlarged  uterus  or  other  pelvic  tumor 15 

13.  Palpating  an  ovarian  cyst  seen  in  sagittal  section .        .16 

14.  Registering  markings  on  transparent  material 17 

15.  Permanent  record  of  an  ovarian  cyst 18 

16.  Photographic  copy  of  a  gauze  tracing 19 

17.  Exposing  the  cervix  uteri  and  the  vault  of  the  vagina  through  a  Nelson  speculum     .  20 

18.  The  knee-breast  posture 21 

19.  Method  of  lifting  up  gluteals  in  knee-breast  posture 22 

20.  Examination  of  the  vagina,  vaginal  vault,  and  cervix  in  the  knee-breast  posture       .  22 

21.  Examining  the  rectum  in  the  left  lateral  (Sims')  posture 23 

22.  Introducing  a  cylindrical  metal  speculum  in  Sims'  posture 24 

23.  Patient  in  Sims'  posture  exaggerated 24 

24.  The  examination  of  a  child  about  six  years  old 25 

25.  Case  of  tubercular  peritonitis  in  colored  child 26 

26.  Organs  on  right  side  whose  affections  are  liable  to  be  confused 28 

27.  Examining  a  ureteral  catheter  with  wax  tip 29 

28.  Examining  the  cervix  and  vault  of  vagina  with  Kelly's  cylindrical  speculum       .        .  32 

29.  Rectal  instruments .35 

30.  Method  of  introducing  long  rectal  speculum 36 

31.  Inspection  of  bowel  with  simple  head  mirror  using  electric  light 37 

32.  AUigator  forceps  used  to  touch  upper  bowel .39 

33.  The  home  of  a  family  of  ten  persons .' 46 

34.  A  court  in  a  crowded  city  district 47 

35.  Toilet  accommodations  for  twenty-two  families 48 

36.  Open-air  gymnasium,  girls'  day.     Patterson  Park,  Baltimore 49 

37.  Model  gymnasium  suit .  59 

38.  Adjustable  desk  with  narrow  box 60 

39.  Desk  similar  to  that  shown  in  Fig.  38  but  not  adjustable         ......  61 

40.  Swimming  pool.     PubHc  bath  system.     Patterson  Park,  Baltimore       ....  62 

41.  Faulty  carriage  in  young  girl 63 

42.  Effect  of  physical  training  upon  faulty  carriage 63 

43.  Case  of  slight  lateral  curvature  of  spinein  school  girl 64 

xiii 


XIV  LIST    OF    ILLUSTEATIOXS. 

FIG.  PAGE 

44.  Same  case,  after  one  month's  systematic  exercise 64 

45.  Case  of   severe   lateral   curvature  of   spine   in   schoolgirl 64 

46.  Same   case,    after,  three   months'    daily    exercise -     .        .        .64 

47.  Interior  of  cadaver  showing  constriction  and  displacement  due  to  corsets    .        .  70 

48.  Shoemaker's  walking  shoe  for  girls 71 

49.  Impression  of  foot  of  school-girl  with  outline  of  shoe  worn 71 

50.  Soles  for  normal  feet — Shoemaker's  soles 71 

51.  Normal  endometrium:  endometrimu  near  menstruation;   endometrium  after  meno- 

pause            81 

51A.     Disc  pessary  for  relieving  incontinence  of  urine 103 

52.  Instruments  used  in  dilation  and  curettage  of  the  uterus 123 

53.  Cervix  caught  and  exposed  by  retracting  the  posterior  vaginal  wall  ....  124 

54.  Dilation  of  the  cervix  with  Goodell-Ellenger  dilator 125 

55.  A  case  of  atresia  of  the  vagina 142 

56.  The  same  ease  of  atresia  showing  lengthening  of  A'agina  from  pressure   .        .        .  143 

57.  A  conglutination  of  the  labia  minora 144 

58.  An    elongate    infantile   ovary 150 

59.  An  early  pregnancy,  showing  globular  enlargement  of  uterine  body   ....  152 

60.  A  placental  polyi^ 166 

61.  A    cervical    polyp 167 

62.  A  large  submucous  myoma 168 

63.  Subinvolution  of  the  uterus 172 

64.  Polypoid    endometritis 175 

65.  Various  sites  of  implantation  of  ovum  in  extra-uterine  pregnancy   ....  195 

66.  Pi'egnancy   in  the  ampulla 196 

67.  Pregnancy   in   a   rudimentary   left   uterine    horn 197 

68.  Right  uterine  tube  the  seat  of  an  extra-uterine  pregnancy 198 

69.  Extra-uterine  pregnancy;  tubal  abortion 198 

70.  Case  shown  in  Fig.  69  with  coagulum  turned  out 199 

70A.     A  myomatous  uterus  resembling  a  fetus  in  its  contour 205 

71.  Posture  in  defecation,  showing  the  efficient  use  of  abdominal  pressure         .        .        .  210 

72.  The   ordinary   sitting   posture   in   defecation    .                 211 

73.  An  adaptation  of  the  modern  sanitary  closet  to  utilize  the  crouching  posture  .        .  212 

74.  Method    of    applying   the    tliermo-light    for   backache 258 

75.  Abscess  of  left  Bartholin's  gland 277 

76.  Treatment  of  vaginitis  in  knee-breast  posture 283 

76A.     Cylindrical  speculum  and  alligator-forceps  applicator,  used  in  treating  vaginitis  284 

76B.     Cylindrical  speculum  for  vaginal  treatment   .        . 284 

76C.     Instrument  and  materials  for  treating  vaginitis 285 

76D.     Appliance  for  distending  vagina  with  water  or  air 286 

77.  Craig's  sharp  curette  for  use  in  endocervicitis 289 

78.  Polypoid  endometritis,  natural   size 292 

79.  A  polypoid  endometritis,  showing  a  section  of  the  endometrium        ....  293 

80.  A  urethral  caruncle  resembling  a  small  dark  hematoma 305 

81.  Different   degrees   of  uterine   displacement 319 

82.  A  retroflexion  which  is  natural  and  cannot  be  corrected 320 

83.  A  case   of  complete   prolapse  of   the   uterus 321 

84.  Showing  manner  of  applying  a  gauze  pack  in  vagina 323 

85.  The   five   most   useful  kinds   of   hard-rubber   pessaries 325 

86.  Method  of  bimanual  reposition  of  a  retroflexed  uterus 326 

87.  An  exaggeration  of  the  normal  anteflexion  of  the  uterus 327 

88.  Showing  manner   of  introducing  a   ring   pessary 328 

89.  Showing  manner  of  introducing  a  Smith  pessary 328 

90.  Showing  manner  of  carrying  a  Smith  pessary  into  place 329 

91.  Showing  a  ring  pessary  in  place 330 


LIST    OF    ILLUSTRATIONS.  XV 

FIG.  PAGE 

92.  A  form  of  pessary   (Menge)   useful  in  some  cases  of  prolapse  of  the  uterus   .        .331 

93.  Different  steps  in  an  operation  for  prolapse  of  the  uterus 332 

94.  An  operation  for  the  cure  of  prolapse .        .        .        .  333 

95.  Treatment  of  pelvic  abscess  by  incision 342 

96.  Some  of  the  causes  of  sterility  brought  together  in  one  diagram 357 

97.  Cyst  of  the   left   Bartholin's   gland 358 

98.  Acute  anteflexion  of  the  uterus 362 

99.  Acute  retroflexion  of  the  uterus  causing  sterility 363 

100.  A    monocystic    tumor    causing    sterility 366 

101.  The  various  sites  in  which  the  gonorrheal  organism  is  apt  to  become  implanted     .  377 

102.  The  gonorrheal  organism,  the  gonococcus  of  Neisser 378 

103.  The  gonorrheal  organism,  the  gonococcus  of  Neisser 378 

104.  A  case  of  gonorrheal  vaginitis  in  a  child  eleven  years  old 382 

105.  Chart  showing  ages  at  which  gonorrhea  is  most  frequently  found  in  little  girls    .  383 

106.  Bent  hairpins  used   as   a   speculum 388 

107.  The  examination  of  a  little  child  for  gonorrheal  infection 390 

108.  Method  of  treating  gonorrhea  in  the  child  in  knee-breast  posture    ....  390 

109.  Specula  of  various  sizes  adapted  to  one  handle  used  in  abortion 466 

110.  Method  of  irrigating  the  infected  uterine  cavity 472 

111.  A  cervico-vaginal  fistula  following  labor 478 

112.  A  complete  perineal  tear  showing  a  characteristically  pentagonal  form    .         .         .  479 

113.  A  typically  relaxed  vaginal  outlet 480 

114.  A  vaginal  outlet  calibrator 481 

115.  A  partial  tear  of  the  perineum 485 

116.  The   sutures   tied   and   the   torn   surfaces   united 485 

117.  A  complete  tear  of  the  perineum  involving  the  sphincter  muscle         ....  485 

118.  A  deeper  tear  of  the  perineum  extending  up  the  left  sulcus 485 

119.  The  physician  dressed  in  a  sterile  gown 486 

120.  Showing  a  fibroid  tumor  beginning  interstitially  and  growing  in  diff'erent  directions  489 

121.  Showing  the  manner  of  growth  of  a  subserous  fibroid 490 

122.  An  interstitial  myoma  distorting  the  cervical  canal 491 

123.  Showing  the  manner  of  growth  of  a  submucous  myoma 492 

124.  A  submucous  polyp  growing  in  a  myomatous  uterus 492 

125.  A  myoma  growing  in  the  anterior  wall  of  the  uterus 493 

126.  A  myoma  growing  in  the   posterior   wall   of   the   uterus 493 

127.  A   myoma    simulating   pregnancy 501 

128.  Fibroid  tumor  beginning  to  undergo  degeneration 502 

129.  Myoma  growing  in  such  a  direction  as  to  cause  pressure  upon  bladder   .        .        .  503 

130.  First  stage  in  operation  for  removal  of  a  fibroid  tumor 511 

131.  Second  stage  in  operation  for  removal  of  a  fibroid  tumor 511 

132.  Squamous-cell  carcinoma  of  the  cervix  with  extension  to  bladder  and  rectum  .        .  514 

133.  Squamous-cell    carcinoma    of    the    cervix   with    cauliflower   mass    springing    from 

anterior    lip 521 

134.  Adeno-carcinoma  of  the  body  of  the  uterus 521 

135.  Three  principal  foci  from  which  cancer  may  originate 522 

136.  Early  stage  of  squamous-celled  cancer  with  disease  confined  to  posterior  lip    .  522 

137.  Extension  of  disease  seen  in  Fig.   136 522 

138.  Disease  still  confined  to  posterior  lip,  formation  of  craterous  cavity  beginning    .  523 

139.  Progress  of  cancer  seen  in  Fig.   138 523 

140.  Early  stage  of  columnar-celled  cervical  cancer  with  areas  of  disease  in  both  lips  .  523 

141.  Progress  of  disease  seen  in  Fig.  140 523 

142.  Diagram   showing  advanced   stage   of   cancer 524 

143.  Serrated  irrigating  curette 526 

144.  Microscopical   appearance   of   normal    endometrium 528 

145.  Microscopical   appearance   of   cancerous   endometrium 529 


XVI  LIST    OF    ILLUSTEATIOXS. 

FIG.  PAGE 

146.  Advanced  stage  of  cervical  carcinoma  witli  formation  of  pyometra    ....  534 

147.  Cervical  carcinoma  with  cervix  exposed  for  curettage 534 

148.  Spoon-handled    scoop    curette •.         .         .  535 

149.  Loop  curette  for  use  in  cancer 535 

150.  Open-air    cystoscope 550 

151.  Manner    of    introducing    open-air    cystoscope 551 

152.  Cystoscope   in   place 551 

153.  Manner  of  inspecting  interior  of  bladder  through  head-mirror 552 

154.  Suction  apparatus  for  treatment  of  cystitis 553 

155.  Dickinson's    two-way   catheter 559 

156.  Metliod  of  irrigation  of  bladder 560 

157.  Metliod  of   continuous  irrigation  of   bladder 563 

158.  Diagrammatic  representation  of  the  displacement  of  abdominal  organs  in  splanch- 

noptosis        598 

159.  Gauze  record  of  marked  displacement  of  stomach 601 

160.  Showing  throe  degrees  of  displacement  of  kidney 607 

161.  Gauze  record  of  displacement  of  right  kidney        .         . 617 

162.  Diagram  showing  nodule  of  ovarian  tissue  remaining  after  removal  of  ovary  and 

causing    menstruation 628 

163.  Diagram  showing  results  of  condition  seen  in  Fig.  162 629 

164.  Pyokolpos  and  pyometra  due  to  complete  stricture  of  the  vagina    ....  639 

165.  Hegar   dilators          . 640 


MEDICAL    GYNECOLOGY. 


CHAPTER    I. 

CONSULTING  ROOM  AND   GYNECOLOGICAL  EXAMINATION. 

(1)  Consulting  room:  Reception  room,  p.  1.     Office  arrangements,  p.  2.     History  taking,  p.  3. 

(2)  Gynecological  examination:  Instruments,  p.  5.     Preparation  of  patient,  p.  6.     Examining 

table,  p.  6.  Abdominal  examination,  p.  6.  Examination  of  stomach,  p.  9.  Vaginal 
examination,  p.  10.  Bimanual  examination,  p.  IL  Gauze  records  of  abdominal  tumors 
and  displaced  viscera,  p.  17.  Inspection,  p.  19.  Leucorrhea,  p.  20.  Examination  in 
knee-breast  position,  p.  23.  Sims  position,  p.  23.  Examination  in  children,  p.  25. 
Examination  standing,  p.  26.  Examination  under  anesthesia,  p.  26.  Examination  of 
virgins,  p.  27.     Pain  as  a  symptom  in  examination,  p.  27.     Notes  of  examination,  p.  29. 

(3)  General  principles  of  treatment:  Outlining  course  of  treatment,  p.  30.     Hygienic  rules,  p.  30. 

Palliative  treatment,  p.  31. 

(4)  Examination  by  rectum,  p.  33. 

THE    CONSULTING    ROOM. 

The  general  practitioner  who  intends  to  practise  gynecology  ought  to 
devote  the  best  space  on  the  first  floor  of  his  house  to  the  reception  of  his 
patients.  Whenever  it  is  possible  he  should  arrange  for  three  rooms :  a 
reception  room;  a  consulting  room,  where  he  meets  his  patients  and 
takes  their  histories;  and  an  examining  room  with  its  paraphernalia, 
where  the  patient  can  prepare  for  the  examination  and  dress  in  comfort 
afterwards. 

The  reception  or  waiting  room  ought  to  be  cheerful,  sunny,  and  clean; 
simply  and  attractively  furnished,  and  well  supplied  with  current  light  lit- 
erature to  beguile  the  period  of  waiting.  Time  is  well  spent  in  exercising 
ingenuity  and  taste  to  secure  articles  of  furniture  and  wall  decorations  which 
show  marked  individuality.  Unfortunately,  not  everyone  realizes  how  impor- 
tant it  is  that  the  first  impression  made  upon  the  patient  should  be  a  pleasant 
one,  tending  to  inspire  confidence  in  the  physician  to  whom  the  patient  is 
about  to  confide  the  most  important  interest  in  life,  her  health.  A  cheery 
kindly  wife,  a  pleasant  secretary,  and  even  a  bright-faced  maid  are  all  assets 
of  much  value  in  helping  to  hold  a  nervous  impatient  patient.  It  is  a  serious 
mistake  to  put  an  office  in  a  basement  in  order  to  get  it  out  of  the  way  or  to 
avoid  sacrificing  the  family  parlor ;  on  the  other  hand,  nothing  is  more  dreary 
than  the  use  of  the  family  sitting  room  for  such  a  purpose.  Moreover,  patients 
are  never  favorably  impressed  by  an  introduction  to  family  portraits  in  crayon, 
nor  by  the  cheap,  gaudy  pictures  and  startling  plush  furniture  which  are 
so  common  everywhere.  Everything  about  the  reception  room  should  express 
2  1 


COXSULTIXCt    room    AXD    gynecological    EXAMIXATION. 


seriousness  of  purpose,  taste,  and  dignity.  In  other  words,  the  physician 
should  consider  what  object  lesson  his  office  shall  teach  to  his  Avaiting  patients. 
It  is  also  a  mistake,  I  feel  sure,  whenever  it  can  be  avoided,  to  force  patients 
to  go  to  a  large  office  building,  use  a  common  elevator,  and  wait  in  groups 
on  benches,  among  the  patients  of  other  doctors.  Such  herding  of  the  suffer- 
ing and  the  sorrowful  robs  life  of  its  refinement. 

Again  no  one  material  quality  in  these  days  teaches  such  important  spir- 
itual lessons  and  appeals  to  patients'  higher  instincts  more  than  scrupulous 
cleanliness  in  their  surroundings.  A  bright  clean  reception  room  and  a  spot- 
less examining  room  are  instantly  accepted  as  guarantee  that  the  physician 
himself  is  a  votary  of  the  modern  doc- 
trine of  antisepsis  and  carries  it  out 
in  all  his  practice. 


O  O, 

Con    s    Lilting 


Room 


nece  ption 


O 


Fig.  1. — A  Simple  Form  of  CoxsTn^TiXG  .\2st>  Re- 
CEPTiox  Room.  The  examining  table  in  the 
consulting  room  is  placed  conveniently  to  the 
light  which  falls  on  the  back  of  the  operator 
as  he  sits  at  the  foot  of  the  table;  this  corner 
of  the  room  is  screened  off. 


Fig.  2. — Aeraxgemext  -stith  Examixixg  Room 
Separated  from  the  Coxsitltixg  Room. 
The  patient  arranges  her  clothing  behind  the 
curtain  indicated  bv  the  waw  lines. 


A  simple  office  arrangement  is  shown  in  Fig-ure  1  in  which,  when  space 
is  limited,  a  portion  of  the  consulting  room  is  utilized  as  an  examining  room. 
A  somewhat  more  elaborate  arrangement  is  shown  in  Figure  2,  including  a 
reception  room,  a  consulting  room,  and  a  separate  examining  room.  The 
toilet  arrangements  in  the  examining  room  are  placed  at  one  end  and  behind 
curtains.  When  more  elaborate  arrangements  still  are  necessary,  I  recom- 
mend the  scheme  in  use  in  my  own  suite  of  apartments.  There  is  first  a  large 
reception  room,  while  adjoining  that  is  the  room  where  the  secretary  and 
typewriter  have  their  desks;  the  consulting  room  is  next  to  this,  and  behind 


HISTORY    TAKING.  3 

there  are  three  examining  rooms.  Washing  and  toilet  facilities  are  provided 
in  a  sejDarate  apartment.  Such  an  arrangement  facilitates  thorough  work  for 
the  specialist  whose  time  is  precious  and  provides  for  the  occasional  patient 
who  has  to  rest  before  leaving  the  house. 

A  nurse  should  always  be  on  hand,  if  possible,  to  receive  the  patient  and 
prepare  her  for  examination,  as  well  as  to  render  any  assistance  required  after- 
wards. She  should  be  dressed  in  a  regular  nursing  costume,  with  a  scrupu- 
lously clean  cap  and  apron,  and  she  ought  to  be  a  woman  of  digTiified  appear- 
ance, preferably  not  too  young.  ISTothing  so  serves  to  tone  the  patient  up 
for  the  ordeal  of  an  examination  as  a  nurse  of  the  right  kind ;  indeed,  she 
will  in  many  instances  be  able  to  hold  on  to  a  patient  who  thinks  of  leaving 
the  physician  for  another.  If  she  has  training  and  ability,  she  will  often 
learn  in  time  to  give  material  assistance  in  investigating  a  case  by  emphasiz- 
ing to  the  doctor  the  matters  of  complaint  and  directing  his  attention  to  those 
issues  which  seem  paramount  to  the  patient. 

The  j)hysician  should  ever  meet  his  patient  with  courtesy  and  a  warm 
personal  interest ;  showing  by  his  manner  that  he  esteems  it  a  high  compliment 
that  she  has  been  willing  to  entrust  him  with  the  care  of  her  health. 

History  Taking. — There  are  three  ways  of  taking  a  history:  (1)  to  fill 
in  an  outline,  such  as  that  given  in  the  text,  and  then  to  add  the  special  mat- 
ters complained  of;  (2)  to  let  the  patient  ease  her  mind  by  first  telling  all 
her  troubles,  after  which  the  outline  is  filled  in ;  or  ( 3 )  a  combination  of 
these  two  methods,  by  listening  and  asking  occasional  questions.  ISTo  one  way 
suits  all  cases.  If  a  patient  is  nervous  and  distressed,  a  few  routine  questions 
directed  in  a  kindly  reassuring  manner,  will  serve  to  give  her  time  to  collect 
herself  and  set  her  at  ease.  If  she  has  her  ailments  much  on  her  mind,  and 
is  impatient  to  pour  them  out,  it  will  be  best  to  let  her  talk  freely  at  first, 
and  then  to  fill  in  the  outline  afterwards.  In  each  instance  a  general  outline 
should  be  filled  in  and  the  history  should  be  written  down.  After  the  name 
follows  the  residence,  age,  social  state  (married  or  not),  and  if  married,  how 
many  children,  miscarriages  and  labors,  as  well  as  the  character  of  the  men- 
strual period,  as  to  regularity  of  intervals,  duration,  amount  of  flow,  and  pain. 
The  occurrence  of  leucorrhea  should  then  be  noted.  I  think  it  is  best,  as  a 
rule,  at  about  this  juncture  to  let  the  patient  tell  her  own  story  briefly  in 
her  own  words,  interrupting  occasionally  if  she  becomes  prolix  or  wanders 
off  to  unimportant  details.  While  the  patient  is  talking,  the  physician  jots 
down  his  notes,  taking  up  the  line  of  her  suggestions  from  time  to  time  and 
asking  more  particularly  and  specifically  regarding  the  nature  of  certain  com- 
plaints. Having  in  this  way  secured  a  complete  history,  the  outline  is  further 
filled  in  by  suitable  questions  relating  to  all  the  other  important  organs  in 
the  body,  including  headaches,  backache,  digestion,  regularity  of  the  bowels, 
urination,  etc.  I  find  it  an  excellent  course,  while  taking  the  history,  to  under- 
line important  facts ;  for  instance,  if  the  patient  has  it  very  much  on  her 
mind  that  she  has  no  children,  I  write  the  word  sterility  and  underscore  it. 


4  COISrSULTING    BOOM    AND    GYNECOLOGICAL    EXAMINATION. 

Date  Diagnosis 


Name 

Occupation  Par 

Instr.  deliv. 
Menstr.  Hist. 


S  TV  M  age  Resides 


Mis 


Le 


Complains  now  of  the  following  symptoms 


Hist,  of  development  of  present  condition 


Patient  of  Dr 
fever 


Gen.  previous  hist.  rheum.  fevers.,  ere. 

Family  Hist:  Husband. 

Physical  Exam,  of   Pelvis  and  Abdomen. 

Vag.  Outlet 

Vagina 

Cervix 

Uterus 

Uterine  tubes  and  ovaries 


Gen.  appearance 

JVeight 

Headaches 

Pack  ache 

Sleep 

Appetite 

Digestion 

Powels 
Urination 

Urinay-y  Anal. 

Pladder 

Rectum 

Kidneys 

Sketch 


Outline  of  Treatment  to  be  followed 


INSTRUMENTS  FOR  GYNECOLOGICAL  EXAMINATION.  5 

If  she  has  severe  headaches,  I  underscore  that  word,  and  so  on.  If  she  has 
been  told  elsewhere  that  she  has  a  tumor,  I  underscore  the  word.  By  thus 
underlining  several  catch  words,  the  physician  is  not  liable  in  the  subsequent 
examination  to  overlook  any  ailment  which  the  patient  has  much  on  her  mind. 
I  sometimes  find  it  helpful,  as  I  take  a  history  or  make  an  examination,  to 
note  down  in  a  short  column,  one  below  another,  the  special  complaints  as  well 
as  any  suggestions  that  occur  to  me  as  to  lines  of  treatment  to  be  carried  out. 
It  is  a  good  plan  to  fill  out  some  such  outline  as  shown  on  the  opposite  page 
in  each  case. 

THE    GYNECOLOGICAL    EXAMINATION. 

After  taking  the  history,  the  next  step  is  the  physical  examination.  It 
is  always  important  to  bear  in  mind  the  purpose  of  such  an  examination,  and 
to  remember  that  especial  care  must  be  taken  to  discover  the  cause  of  the 
patient's  discomfort  or  suffering.  In  making  a  gynecological  examination  it 
is  necessary  to  bear  in  luind  that  the  investigation  of  the  pelvic  organs  is  always 
a  trial  and  source  of  distress  to  the  patient  who  is  not  an  habituee  of  the 
office.  For  his  own  sake  as  well  as  for  the  patient's,  and  as  a  mark  of  the 
respect  which  he  owes  to  all  womankind,  the  physician  will  always  carefully 
protect  the  patient  and  avoid  all  undue  exposure.  The  methods  of  examina- 
tion in  this  country  and  in  Great  Britain  have  thus  far  ever  been  charac- 
terized by  a  modesty  and  a  consideration  for  the  feelings  of  the  patient  which 
do  honor  to  our  profession.  When  that  sense  of  modesty  becomes  blunted, 
our  specialty  will  have  taken  a  lamentable  and  a  distinctly  retrograde  step. 
Great  care  should  also  be  taken  not  to  expose  a  patient  even  when  she  is  under 
anesthesia  and  unconscious,  during  preparation  for  an  operation. 

The  first  examination  should  include  a  consideration  of  every  important 
organ  of  the  body.  The  physician  must  never  forget  that  a  large  percentage 
of  his  patients  have  other  ailments  than  those  which  are  covered  by  gyne- 
cology. The  condition  of  the  chest  must  be  looked  into,  and  inquiry  made 
into  a  history  of  tuberculosis,  pleurisy,  or  any  form  of  heart  disease.  After 
a  survey  of  the  other  organs,  the  physician  concentrates  his  attention  upon  the 
abdomen,  which  must  be  studied  from  thorax  to  pelvic  diaphragm  with 
extreme  care. 

Instruments, — The  few  instruments  necessary  to  the  gynecological  arma- 
mentarium in  the  examining  room  are: 

Sims'  speculum, 

ITelson  trivalve  specula,  2  sizes,  large  and  small, 

Kelly  cylindrical  speculum,  with  long  handle,  for  use  in  the  knee-breast 
position. 

Dressing  forceps. 
Tenaculum. 
Uterine  sound. 


6  constjltijstg  eoom  and  gynecological  examination. 

Traction  or  bullet  forceps. 
Packer. 
Applicators. 
Scarifier. 

Cotton  and  wool  i^ledgets,  of  various  sizes. 

I^itrate  of  silver  solutions  of  varying  strengtlis,  from  5  to  40  per  cent,  in 
2  oz.  bottles  of  amber  glass. 
Borogiycerid,  6  oz. 

Metal  instruments  are  best  sterilized  in  a  fisb-kettle  by  boiling  in  a  1  per  cent 
solution  of  sodium  carbonate  for  five  minutes.  After  every  use  tbe  instru- 
ments should  be  washed  with  soap  and  hot  water  and  re-sterilized.  There  is 
great  risk  of  spreading  gonorrhea  and  even  syphilis  by  the  use  of  contaminated 
instruments.  An  ordinary  washing  or  rinsing  in  hot  water  does  not  serve  to 
render  an  instrument  sufiiciently  clean  for  use.  After  sterilization  all  the 
instruments  should  be  placed  in  an  orderly  manner  on  a  clean  towel,  laid  on 
a  white  porcelain  ware  tray,  and  covered  with  another  towel  so  as  not  to  offend 
the  eye  of  the  patient.  The  physician  ought  to  wash  his  hands  briefly  witH 
soap  and  water  and  a  scrubbing  brush  before  each  examination,  and  thoroughly 
immediately  after  it  is  over.  A  sample  of  urine  should,  as  a  rule,  be  secured 
as  part  of  the  examination.  The  most  satisfactory  specimen  is  that  which  is 
taken  by  a  nurse,  after  cleansing  the  orifice  of  the  urethra,  with  a  sterile  glass 
catheter,  having  a  piece  of  rubber  tubing  six  inches  long  on  the  outer  end, 
which  serves  to  convey  the  urine  into  a  sterile  test-tube. 

Preparation  of  the  Patient. — The  patient  should  be  prepared  for  the  exam- 
ination by  removing  all  clothes,  baring  the  abdomen  from  thorax  to  symphysis. 
She  ought  always  to  remove  her  corsets.  The  physician  ought  not  to  consent 
to  attempt  an  examination  hampered,  for  example,  by  a  union  suit  of  under- 
wear or  by  corsets.  If  the  patient  deems  her  condition  serious  enough  to 
compel  her  to  apply  to  a  physician  for  examination,  it  is  at  least  worth  her 
while  to  offer  him  the  best  possible  opportunity  to  make  his  examination  with 
thoroughness. 

The  best  examining  table  is  a  simple  rectangailar  structure,  like  a  big  box 
with  drawers  or  like  a  kitchen  table,  upholstered  with  leather  or  covered  with 
a  folded  blanket  and  clean  sheets  (see  Fig.  3)  ;  two  supports,  projecting  about 
eight  inches  from  the  foot  of  the  table,  support  a  crossbar  which  may  be 
notched  so  as  to  catch  the  heels.  The  under  part  of  the  table  may  be  con- 
veniently supplied  with  drawers  and  utilized  for  holding  linen,  supplies,  etc. 
The  measurements  of  the  examining  table  that  I  use  are:  Leng-th  forty-five 
inches,  breadth  twenty-four  inches,  height  thirty  inches.  I  prefer  a  table  of 
this  kind  to  the  various  examining  chairs  advertised,  although  I  began  my 
work  with  a  chair. 

Abdominal  Examination. — The  examination  is  first  made  with  the  patient 
lying  on  her  back.     If  the  examiner's  hands  are  cold,  they  should  be  immersed 


ABDOMINAL    EXAMINATION.  / 

in  warm  water,  after  which  the  abdomen  is  palpated.  It  is  my  custom,  and 
I  think  it  is  the  best  plan,  first  to  feel  the  upper  abdomen,  running  the 
hand  across  it  and  making  pressure  at  several  points,  to  make  sure  there  are 
no  undue  prominences,  or  areas  of  tenderness,  resistance,  or  fluctuation.  I 
then  examine  the  right  hypochondrium,  and  if  no  resistance  is  felt, 
use  both  hands,  pressing  deeply  into  the  right  flank  and  feeling  for  the 
kidney.  If  this  is  not  discovered  at  once,  I  tell  the  patient  to  breathe 
deeply,  and  this  may  bring  it  down  between  the  fingers.     Sometimes  with  the 


1 


Fig.  3. — ^The  Gynecological  Examining  Table.  The  top  is  covered  with  leather,  well  padded,  on 
this  is  placed  a  blanket  covered  with  a  linen  sheet.  A  drainage  cushion  is  serviceable  in  protecting 
the  table  from  contamination  from  discharges.  In  my  office  I  sometimes  use  a  much  smaller 
cushion  than  that  shown  in  the  figure.  The  drawers  serve  for  the  storage  of  clean  linen,  towels, 
dressings,  pessaries,  etc. 

fingers  pressing  in  deeply  from  behind  and  from  the  front  simultaneously, 
a  wedge  within  is  felt,  as  the  patient  takes  a  deep  breath,  descending  from 
under  the  ribs,  entering  the  angle  and  pressing  the  fingers  gently  apart; 
with  the  act  of  expiration,  the  wedge  retires  back  under  the  ribs  again.  In 
this  way,  the  lower  pole  of  the  kidney  can  often  be  felt.  With  a  deep 
inspiration  it  descends  until  it  is  felt  as  far  as  the  renal  notch,  the  second 
degree  of  displacement;  or  again,  it  slips  down  entirely  below  the  fingers, 
which  now  lie  above  the  upper  pole,  when  the  descent  is  one  of  the  third 
degree.  If  the  kidney  cannot  be  felt  in  this  way,  it  can  sometimes  be  found 
by  raising  the  head  and  shoulders  and  letting  the  patient  lie  on  the  left  side, 
when  the  intestines  drop  away  from  the  side  under  examination.  On  sitting 
up  and  leaning  forward,  or  on  standing  up  and  leaning  forward,  a  loose  kid- 


8  COXSULTIXG    KOOil    AXD    GYISrECOLOGICAL    EXAMII^-ATION. 

ney  can  often  be  felt  to  best  advantage;  sometimes  a  markedly  displaced 
kidney  becomes  evident  only  after  the  patient  has  been  walking  about  a  great 
deal  just  before  the  examination.  The  edge  of  the  liver  at  times  feels  sur- 
prisingly like  a  kidney,  but,  as  a  rule,  the  sharpness  of  the  edge  serves  to 


Fig.  4. — Piezometer  Used  to  Register  the  Depth  and  Amount  op  Pressure  Made.     It  is  also 

A  Paix  Index. 


distinguish  the  liver.  In  thin  patients,  a  distended  gall  bladder  can  often 
be  felt,  hanging  pendulous  into  the  abdomen  from  beneath  the  margin  of  the 
ribs.  It  is  best  to  complete  the  examination  of  all  the  other  abdominal  organs 
before  examining  the  stomach. 


ABDOMINAL    EXAMINATION.  9 

The  way  to  outline  the  stomach  is  to  give  a  teaspoonful  of  the  bicar- 
bonate of  soda  dissolved  in  a  small  glassful  of  water,  following  this  at  once 
with  a  teaspoonful  of  tartaric  acid  in  a  like  amount  of  water.  The  patient 
must  drink  lying  down,  and  she  must  resist  the  impulse  to  belch  up  the  gases 
which  at  once  begin  to  distend  the  stomach  visibly  under  the  abdominal  wall. 
This  examination  is  best  put  last.  The  colon  and  the  vermiform  appen- 
dix are  next  palpated.  If  the  patient  complains  of  any  tenderness  or  there  is 
any  reason  to  suspect  ajDpendicitis,  a  good  way  to  compare  the  relative  tender- 
ness on  the  right  and  on  the  left  sides  is  to  use  a    piezometer   (see  Fig.  4), 


it'     ^'t 


"\ 


Fig    5 Deviation  of  the  Sigmoid  Flexure.     The  bowel  crosses  the  promontory  of  the  sacrum  on 

the  right  side,  then  returns  to  the  left  pelvic  brim,  and  drops  into  the  pelvis  just  behind  the  uterus. 


which  is  designed  to  register  accurately  the  amount  of  pressure  necessary  to 
produce  pain,  as  well  as  to  record  the  resistance,  by  means  of  the  depression 
made  in  the  abdominal  wall.  The  piezometer  consists  of  a  spiral  spring  in 
a  hollow  cylinder  within  which  travels  a  piston  ending  in  a  button.  If  the 
button  is  pressed  into  the  abdominal  wall,  the  amount  of  pressure  made  is 
measured  on  an  index,  while  the  depth  to  which  the  button  depresses  the  wall 
is  measured  by  a  wheel  which  slips  freely  up  and  down  the  shaft  of  the  piston. 
The  sigmoid  flexure  is  palpated  to  discover  any  accumulations  of  fecal 
matter  (see  Fig.  5).     The   pelvis    is  palpated  above  the  symphysis,  by  mak- 


10 


CONSULTING  EOOM  AND  GYNECOLOGICAL  EXAMINATION. 


ing  pressure  inwards  towards  the  pelvic  floor  and  noting  any  areas  of  resistance 
or  any  tender  spots. 

Vaginal  Examination.^ — The  pelvic  organs  are  next  examined  by  the  vagina, 
(a)  by  touch  and  (b)  by  insi^ection.  In  making  such  an  examina- 
tion, the  points  to  be  noted  by  inspection  are : 

(1)  Changes  in  position  (displacements). 

(2)  Peculiarities  of  form,  size,  or  consistency,  such  as  are  produced  by 
inflammations  or  tumors. 

(3)  Alterations  in  sensibility. 

By  touch  the  finger  may  recognize  a  lax,  everted  condition  of  the  vaginal 
orifice,  often  found  after  multiple  childbirth.  The  vaginal  walls  are  next 
examined  and  may  be  found  rugose  and  in  their  normal  condition,  or  often, 
as  in  women  who  have  borne  many  children,  flaccid,  smooth,  and  pouting. 
We  thus  note  at  once  by  touch  whether  or  not  the  vaginal  orifice  is  tightly 


Fig.  6. — Bimanual,  Examination  by  Vagina  and  Abdomen.  The  index  finger  of  the  right  hand  and 
the  index,  middle,  and  third  fingers  of  the  left  hand  are  easily  brought  close  together  and  used  to 
question  the  structures  lying  between  them. 

closed,  and  whether  the  vagina  occupies  its  normal  relations  to  the  pelvic  floor, 
as  it  stretches  back  over  the  floor  of  the  pelvis  to  the  cervix  which  lies  in  the 
sacral  hollow,  or  whether,  on  the  other  hand,  the  orifice  is  broken  down  and 


VAGINAL    AND    BIMANUAL    EXAMINATION. 


11 


the  tissues  are  pouting,  forming  what  has  been  appropriately  called  a  sacro- 
pubic  hernia  (Berry  Hart).  The  examining  finger  also  notes  carefully  a 
cervix  in  descensus,  that  is  to  say,  lying  low  down  in  the  vagina,  perhaps  just 
behind  the  symphysis  pubis,  and  the  cervix  in  its  normal  position  well  back 
in  line  with  the  ischial  spines.  The  form  and  size  of  the  cervix  are  noted. 
The  conical  cervix,  with  a  rounded  hard  surface,  is  readily  distinguished 
from  the  fissured,  infiltrated  cervix,  or  a  friable  cervix  converted  into  a  cauli- 
flower mass  by  malignant  disease.  If  there  is  much  vaginal  discharge,  it  is 
well  to  wear  ^  thin  glove  in  order  to  protect  the  hand  during  such  examina- 
tions, and  avoid  even  the  slightest  risk  of  carrying  over  an  infection  to  the 
next  patient,  perhaps  a  woman  in  labor. 


Fig.  7. — Bimanual,  Examination  of  the  Uterus.  The  upper  hand  indents  the  walls  of  the  abdomen 
and  rests  upon  the  fundus  while  two  fingers  of  the  lower  hand,  introduced  into  the  vagina,  rest 
upon  the  cervix.     Palpation  in  this  way  reveals  the  size  and  form  of  the  uterus. 


Bimanual  Examination. — The  examiner  next  investigates  the  condition  and 
positions  of  the  deeper  pelvic  organs  by  using  his  free  hand  through  the 
abdominal  wall  to  press  down  through  the  superior  strait  and  act  conjointly 
with  the  vaginal  hand  (see  Figs.  6  and  7).  A  bimanual  examination 
reveals  the  exact  position  of  the  uterine  body,  whether  inclined  for- 
ward in  normal  anteposition,  or  backward  in  retroversion  or  retroflexion. 
Then,  displacing  the  uterus  to  the  riglit  or  to  the  left,  the  condition  of  the 
uterine  tubes  and  of  the  ovaries  is  investigated.     If  there  is  a  simple  enlarge- 


12 


CO:^rSULTI]^G    EOOM    and    gynecological    EXAMINxiTION. 


ment,  it  is  easily  detected  as  shoAvn  in  the  figure;  an  enlargement  associated 
with  adhesions  is  recognized  as  a  more  or  less  immovable  mass  to  one  side  or 
other  of  the.  body  of  the  uterus.  During  the  bimanual  examination,  the 
mobility  of  the  organs  is  tested.  The  question  must  be  asked  and 
answered  whether  the  uterus  has  its  normal  play,  and  whether  or  not  the 
ovaries  are  free.  This  question  of  mobility  of  the  uterus  becomes  a  matter  of 
the  utmost  importance  in  dealing  with  cancer.  When  a  cancer  is  found  in  the 
cervix,  the  first  important  query  is  this:  Has  the  disease  extended  beyond 
the  uterus  into  the  broad  ligaments  in  the  direction  of  the  pelvic  wall?  The 
answer  to  this  inquiry  is  found  by  attempting  to  throw  the  uterus  up  and 
down  in  the  pelvis  thus  performing  a  sort  of  ballottement  with  it;  if  it  feels 
fixed  or  hinged  on  one  side,  this,  as  a  rule,  constitutes  a  contra-indication  to 
a  radical  operation.  It  must  never  be  forgotten,  however,  in  seeking  to  give 
the  patient  the  benefit  of  every  reasonable  doubt,  that  the  fixation  may  be 


Fig.  8. — BmANUAL  Examination  by  Rectum  and  Abdomen.  It  is  easily  seen  from  this  figure  to 
what  depth  the  index  finger  of  the  left  hand  can  be  carried  into  the  rectum,  in  this  way  reaching 
the  posterior  surface  of  the  uterus  and  both  tubes  and  ovaries. 

effected  by  inflammatory  and  not  by  cancerous  infiltration,  and  that  it  may 
also  be  due  to  an  inflamed,  adherent  tubo-ovarian  mass  in  one  or  both  sides. 
The  clearest  approach  to  the  pelvic  organs  above  the  vaginal  vault  is  by  the 
combined  rectal  and  abdominal  examination  (see  Fig.  8).  The  uterus,  tubes, 
and  ovaries  are  felt  in  this  wav  with  the  utmost  distinctness. 


BIMANUAL    EXAMINATION. 


13 


Before  -witlKlrawiug  the  finger  from  tlie  vagina,  tlie  bladder  is  palpated 
through  the  anterior  vaginal  wall,  and  the  little  delicate  ureteral  cords  are  felt, 
stretching  from  the  position  of  the  internal  ureteral  orifice  around  the  pelvic 
wall  to  the  side  of  the  cervix  in  the  lateral  fornix  above ;  the  normal  ureters 
are  always  quite  small,  freely  movable  cords.     Any  enlargement,  or  thicken- 


FiG.  9. — Trimanual  Examination  Showing  the  Index  Finger  in  the  Rectum  Palpating  the 
Posterior  Surface  of  the  Uterus  while  the  Thumb  of  Same  Hand  Locates  the  Position 
OF  and  Fixes  the  Cervix. 


ing,  or  irregularity  indicates  disease  of  the  ureter  and  of  the  kidney  on  the 
same  side.  By  thus  discovering  a  thickened  ureter  in  a  case  of  pyuria,  a 
diagnosis  of  tuberculosis  of  the  kidney  can  often  be  made  within  a  few  seconds. 
Such  a  diagnosis  must,  of  course,  be  confirmed  by  further  topical  examination 
and  by  urinary  analysis.  If  the  uterus  is  inclined  to  slip  from  under  the 
examining  finger  in  the  ordinary  recto-abdominal  examination,  it  is  sometimes 
a  good  expedient  to  fix  the  lower  pole  of  the  uterus  with  the  index  and  middle 
fingers  in  the  rectum,  at  the  same  time  carrying  the  thumb  into  the  vagina 
(see  Fig.  9),  and  so  locating  and  fixing  the  cervix;  making  a  sort  of  tri- 
manual  examination,    in  which  the  uterus  sits  poised,  as  it  M^ere,  on  the 


14 


cojstsulting  room  and  gynecological  examination. 


fingers  and  thumb  of  the   hand   operating  throngh  the   inferior   strait,  while 
the  upper  hand,   palpating  through  the  abdominal  wall,   examines  the  body 


Fig.  10. — Beviantjal   Examixatiox   Showij^g  the  Method  of  Palpating  and   Distingthshtng  a 
Fibroid  Tumor  on  the  Posterior  Sl'Rface  of  the  Uterus. 

of  the  uterus  on  all  sides.  (The  method  of  examining  the  bladder  is  given 
in  Chap.  XXII.) 

"When  any  enlargement  of  the  intrapelvic  structures  is  felt  during  a 
bimanual  examination,  the  fundamental  question  to  be  answered  is  whether 
the  growth  is  uterine  or  ovarian? 

A  uterine  tumor  (see  Fig.  10)  can  be  best  outlined  in  a  combined 
rectal  and  abdominal  examination,  as  shown  in  the  figure.     The  uterine  growth 


Fig.  11. — Bimanual  Examination  Showing  the  Method  of  Detecting  an  Ovarian  Tutmor  Lying 
Back  of  the  Uterus  and  Displacing  it  Forward. 


BiMANtfAL    EXAMINATION. 


15 


is  in  this  way  felt  to  be  continuous  with  the  uterine  wall,  from  the  cervix  up 
on  to  the  growth  and  from  the  fundus  down  over  its  convexity.  In  moving 
the  uterus  the  enlargement  at  once  moves  with  it,  and  there  is,  as  a  rule,  no 
appreciable  interval  between  the  two.     The  tumor  is  then  uterine. 

In  such  a  case  as  that  shown  in  the  figure,  the  next  question  is  whether  the 
uterus  is  in  anteflexion  with  a  tumor  imbedded  in  its  posterior 
wall  or  whether  it  is  in  retroflexion  with  the  tumor  growing 
from  its  anterior  wall.  This  question  is  usually  easy  to  answer,  as  a 
uterine  tumor,  which  is  practically  always  a  fibroid,  is  denser  than  the  nor- 
mal uterus,  has  a  more  rotund  form,  and  is  often  nodular;  furthermore,  a 


Fig.  12. — The  Examiner  is  Engaged  in  Outlining  the  Enlarged  Uterus  or  Other  Pelvic  Tumor. 
The  outer  limits  of  the  tumor  are  marked  out  in  a  series  of  dots  with  the  aniline  pencil  as  seen  in  the 
figure. 


minute  handling  of  the  mass  frequently  shows  just  a  little  play  of  motion 
between  the  uterine  body  and  the  tumor.  The  relation  of  the  normal  ovaries 
to  the  uterus  also  serves  to  mark  out  the  uterine  body.  The  uterine  sound 
carried  up  on  to  the  uterus  gives  the  direction  of  the  cavity  at  once,  and  shows 
whether  it  is  in  front  of  or  behind  the  uterus. 

An  ovarian  tumor  (see  Fig.  11)  usually  lies  more  or  less  lateral  to 
the  uterus,  and  is  distinctly  fluctuating,  while  there  is  also  a  well  defined 
interval  between  the  tumor  and  the  womb.  Palpation  of  the  smaller  struc- 
tures about  the  tumor  with  careful  attention  sometimes  reveals  its  connection 
with  the  uterus  by  the  ovarian  ligament.     If  the  uterus  is  then  caught  with  a 


GAUZE    KECOEDS    OF    ABDOMINAL    TUMOKS    AND    DISPLACED    VISCERA.  17 


tenaculum  forceps  and  pulled  down  towards  the  vaginal  outlet,  there  is  at  first 
an  indistinct  movement  on  the  part  of  the  uterus,  followed  by  a  more  tardy 
communicated  movement  on  the  part  of  the  tumor.  If  the  tumor  is  pushed 
upward  in  the  direction  of  the  umbilicus,  the  uterus,  as  a  rule,  does  not  follow 
it  at  once.  An  additional  point  in  favor  of  an  ovarian  tumor  is  the  discovery 
of  a  normal  ovary  on  one  side,  while  on  the  opposite  side  the  ovary  cannot  be 
felt,  its  place  being  taken  by  a  cystic  tumor. 

Gauze  Records  of  Abdominal  Tumors  and  Displaced  Viscera.- — I  have  found 
the  method  about  to  be  described  of  the  utmost  value  in  making  permanent 
records  of  my  cases  of  abdom- 
inal tumors  and  misplaced 
organs,  such  as  stomach  and 
kidneys;  and  it  is  one  I 
would  earnestly  recommend 
to  ^practitioners  at  large,  who 
can  easily,  with  a  little  prac- 
tice, acquire  the  slight  degree 
of  skill  necessary  to  make  the 
tracings.  There  are  several 
reasons  wdiy  this  method  of 
studying  cases  is  important. 
In  the  first  place,  it  is  con- 
ducive to  a  more  careful  ex- 
amination and  palpation  of 
the  tumor.  It  requires  more 
time  than  an  ordinary  inves- 
tigation and  therefore  is  of 
advantage  to  both  operator 
and  patient.  Again,  the  de- 
liberation necessary  is  justly 
calculated  to  impress  the  pa- 
tient with  the  fact  that  the  ex- 
amination is  being  made  with 
that  extreme  care  and  pains- 
taking attention  to  the  more 
minute  as  well  as  the  large 
features  of  the  case  which  a  grave  situation  demands.  The  first  step  is  to  make 
an  outline  of  the  tumor  by  means  of  a  series  of  dots  on  the  surface  of  the  skin 
with  an  aniline  pencil,  while  the  bimanual  examination  is  being  made  (see 
Fig.  12).  If  the  marks  are  not  easily  made  on  the  skin,  it  will  be  sufiicient 
to  wet  the  surface  with  a  little  alcohol.  By  giving  the  fingers  a  little  vibra- 
tory movement,  as  shown  on  the  left  hand  in  Figure  13a,  the  outlines  of  the 
cyst  or  tumor  are  more  delicately  appreciated,  since  each  slightest  thrill  is  com- 
municated to  the  vaginal  fingers  resting  on  the  lower  pole  of  the  growth.     After 


->%- 


..     i J 

Fig.  14. — After  the  Examiner  has  Outlined  the  Tumor 
ON  THE  Skin  in  Aniline  and  has  Marked  Out  such 
Landmarks  as  the  Anterior  Sxtperior  Spine,  the 
Symphysis  and  the  Margin  of  the  Ribs,  He  then 
Lays  a  Glass  Plate  on  the  Abdomen,  Covered  with 
THE  Transparent  Material  on  which  He  Registers 
the  Markings  on  the  Skin,  easily  seen  through 
the  Glass.  A  crayon  or  carbon  pencil  is  better  for  this 
purpose  than  an  aniline  pencil. 


18 


CONSULTING    ROOM    AND    GYNECOLOGICAL    EXAMINATION. 


the  tinnor  lias  been  dotted  out  in  outline  and  the  dots  have  been  connected  by  a 
continuous  line,  the  landmarks  of  the  abdomen,  as  the  symphysis,  the  anterior 
superior  spine,  and  the  margins  of  the  ribs  are  outlined  with  aniline  (see 
Fig.  136).     The  next  step  is  to  make  a  transfer  of  the  record  on  the  abdomen 


Fig.  15. — Shows  a  Permanent  Record  of  an  Ovarian  Cyst  and  the  Outlines  of  the  Abdomen. 
The  little  figure  in  the  lower  right-hand  corner  shows  the  relation  of  the  uterus  to  the  tumor,  the 
symphysis  lies  below. 

to  a  piece  of  stiffened  gauze  material  ( Suisse,  nainsook,  or  organdie)  laid  over 
the  abdomen  upon  a  glass  plate  as  shown  in  Figure  l-i.  The  skin  markings 
are  all  visible  through  the  glass,  and  it  is  an  easy  matter  to  reproduce  them 


INSPECTION. 


19 


with  a  crayon  pencil  as  tliey  are  projected  npon  tlie  gauze,  which  is  carefnlly 
held  immovable  while  the  transfer  is  made.  The  appearance  of  such  a  gauze 
record  is  shown  in  Figure  15. 

The  record  is  then  filed  away  to  serve  as  a  literal  transcript  of  the  case  in 
lieu  of  an  ordinary  diagrammatic  sketch,  or  for  future  comparison,  in  case  the 
patient  returns  at  a  subse- 
quent  time    and    it   is    im- 
portant   to    know    whether 
the  tumor  has  grown  or  not. 

In  using  the  record  to 
test  the  growth  or  change 
in  position  of  the  tumor, 
an  entirely  fresh  record 
should  be  made  at  the  sec- 
ond visit,  independently  of 
the  first  one.  Then  the 
two  gauzes  should  be  laid 
one  on  the  other,  when  any 
difi^erence  in  size  is  easily 
appreciated. 

For  the  sake  of  dem- 
onstration I  give  a  photo- 
graphic copy  of  the  gauze 
record  of  a  fibroid  tumor 
(see  Fig.  16).  I  have  a 
large  number  of  these  rec- 
ords which  not  only  serve  the  purposes  indicated,  but  are  most  valuable  in 
teaching  as  well. 

Inspection. — The  examiner  next  proceeds  to  inspect  the  vulva,  the 
vagina,  and  the  cervix.  A  broken  down  or  gaping  vulvar  orifice  is  often 
a  most  conspicuous  object.  The  vulvovaginal  glands  (Bartholin's  glands) 
should  be'  examined,  as  they  are  sometimes  the  seat  of  chronic  gonorrheal  infec- 
tion. By  squeezing  the  external  urethral  orifice,  a  lingering  infection  at  that 
point  is  brought  to  light  in  the  form  of  a  little  drop  of  pus  exuding  onto  the 
surface.  A  cystocele  and  a  rectocele  are  formed  by  the  walls  of  an  everting 
vagina,  associated  with  a  descent  of  the  uterus.  The  upper  vagina  and  the 
cervix  can  sometimes  be  seen  in  these  cases  by  simply  pulling  back  the  peri- 
neum with  two  fingers.  For  making  a  specular  examination  of  the  vagina, 
I  like  best  on  the  wdiole  a  trivalve  speculum  (JSTelson's).  This  is  easily  intro- 
duced by  drawing  back  the  posterior  wall  of  the  vagina  with  one  or  two  fingers, 
at  the  same  time  slipping  the  well-oiled  blade  into  the  vagina,  pressing  a  little 
backward  so  as  not  to  impinge  upon  the  urethra  or  strike  the  pubic  arch. 
The  position  of  the  cervix  having  been  located  by  the  finger,  the  end  of  the 
speculum  is  directed  downward  and  backward,  so  that  when  it  is  opened,  the 


Fig.  16. — A  Photographic  Copy  of  a  Gauze  Tracing  made  in 
THE  Case  of  a  Large  Fibroid  Tumor  of  the  Uterus.  The 
name  and  clinical  data  attached  to  the  corner  are  omitted. 


20 


CONSULTING    EOOM    AND    GYNECOLOGICAI,    EXAMINATION. 


cervix  lies  plainly  in  view  between  the  three  blades  (see  Fig.  17).  The  color 
of  the  vagina  is  noted,  and  any  discharges  found  are  spread  out  on  a  slide 
for  microscojjic  examination.     When  there  is  much  leucorrhea,   a  large  infil- 


FiG.  17. — Exposing  the  Cervix  Uteri  and  the  Vatti^t  of  the  Vagina  through  the 

Nelson  SPEcuLmi. 


trated  cervix  is  often  found  pouring  out  a  tenacious,  mueo-purulent  material 
(endocervicitis).  This  is  the  common  sign  of  a  chronic  gonorrheal  infection, 
or  of  a  simple  chronic  cervical  infection  following  childbirth.  The  condition 
is  not  a  sign  of  endometritis  farther  up. 

Leucorrhea. — ^\Vhen  a  patient  complains  of  leucorrhea,  it  is  always  im- 
portant to  determine  the  source  of  the  discharge.  As  a  rule,  it  is  either 
vaginal  or  cervical.  Cervical  discharges  may  come  from  the  mucous 
lining  of  the  cervical  canal  from  the  external  up  to  the  internal  os.  A  dis- 
charge from  the  uterine  cavity  (endometritis)  is  rare;  I  declare 
this  in  direct  opposition  to  the  commonly  received  opinion.  The  vaginal  is 
readily  distinguished  from  the  cervical  discharge  by  its  more  milky,  thin,  and 
uniform  consistency;  in  pregnancy  it  may  be  of  a  curdy  character.  The  cer- 
vical discharges,  on  the  other  hand,  are  always  stringy,  mucoid,  or  muco-puru- 
lent.  In  a  doubtful  case  it  is  sometimes  a  good  plan,  after  cleaning  out  the 
vagina,  to  prove  the  source  of  the  vaginal  discharge  by  placing  a  tampon  in 


LEUCOKKIIEA. 


21 


the  vagina,  adjusting  it  carefully  to  the  cervix  and  vaginal  vault.  The  patient 
should  then  keep  quiet  for  a  few  hours,  when  the  tampon  is  carefully  removed 
and  inspected.  If  the  discharge  is  vaginal,  the  whole  tampon  is  wet;  if  it  is 
cervical,  the  accumulation  is  more  in  a  little  pool  in  the  depression  made  by 
the  cervix  (Schultze's  method). 

I  hear  a  great  deal  in  correspondence  with  physicians  in  different  parts 
of  the  country  and  from  patients  who  come  for  treatment,  of  "  ulcerations  " 
and  "  erosions  of  the  womb."  To  most  women,  "  ulceration  "  is  a  grave,  well 
nigh  incurable  malady,  accountable  for  all  sorts  of  lower  abdominal  aches  and 
pains  and  general  ill  health.  It  is  important  to  call  the  attention  of  the  pro- 
fession to  the  fact  that  ulceration  of  the  neck  of  the  womb  is  an  extremely 
rare  ailment,  which  not  one  physician  in  five  hundred  has  ever  seen.  The 
condition  called  ulceration  is,  as  a  rule,  an  ectropion  of  the  cervix,  commonly 


1  S. TlIK  KXKK-T|-RF,AST  PoSTTTI?K.  CTVTKG  A  PERFECT  ExPOSTTRE  IN  EXAMINING  ANY  OF  TITF  IToLI.OW 

Pelvic  Viscera,  the  Rectum,  the  Vagina,  or  the  Bladder.  Note  the  approximation  of  the 
chest  to  the  table,  the  spreading  out  of  the  elbows,  and  the  direction  of  the  face  to  one  side,  as  well 
as  the  slight  incurvation  of  the  back.  The  patient  should  be  at  rest  and  feel  well  supported  in  this 
posture.  Most  cases  do  well  with  the  thighs  at  an  angle  of  about  65  degrees  to  the  body  as 
shown  here  in  the  figure.  In  other  cases  a  better  exposure  is  secured  when  the  thighs  are  vertical 
and  the  angle  is  about  50  degrees,  while  in  a  few  others  still  the  relaxation  is  best  when  the  thighs 
are  drawn  up  a  little  under  the  abdomen  and  the  angle  is  about  40  degrees. 


associated  with  laceration.  It  does  not  demand  treatment,  unless  there  is  at 
the  same  time  an  infection  of  the  glands  causing  the  discharge  of  a  muco- 
purulent secretion.  Anything  causing  congestion  of  the  cervix,  or  a  swelling 
up  of  its  mucosa,  will  cause  the  cervical  mucosa  to  roll  out  into  the  vaginal 


Fig.  19  — ExjoniN-ATTOX  zn"  Kxee-breast  Posttee  shotvixg  ^Iethod  of  Lifttxg  up  Glttteai-s  axd 
Posterior  Vagixai,  Wall  thts  Lettln'g  Air  rxro  the  Vagin^a  foe  the  Lsteoductiox  of  the 
Speculttm  or  the  Examixatiox  of  the  Bladder. 


Fig.  20. — ExA^r^^■ATIo^"  of  the  Vagina,  "S'agixal  Vatt-t,  axd  CER^•IX  ix  the  Kxee-breast  Posture 
A^^TH  the  Kelly  Ctlixdrical  !Metal  Speculum  haatxg  a  Stout  Haxdle. 
22 


EXAMINATION     IN"    KNEE-BEEAST    POSITION. 


23 


surface,  where  it  appears  as  a  dark  red  spot  surrounding  the  os;  but  this  is 
not  a  laceration  or  an  erosion.  Treatment  of  this  condition,  as  a  rule,  is 
misapplied. 

Examination  in  the  Knee-breast  Position. — An  examination  in  the  knee- 
breast  position  (see  Fig.  18)  is  often  of  the  utmost  service  in  exposing  every 
part  of  the  vagina,  with  the  cervix,  to  view.  This  posture  is  of  the  greatest 
utility  in  applying  treatments  to  the  inflamed  vaginal  walls,  as  the  rugse  are 


Fig.  21. — Examining  the  Vagina  in  the  Left  Lateral  Position.  The  upper  buttock  is  raised 
and  the  speculum  slipped  into  the  vagina.  The  posterior  wall  is  then  retracted  so  as  to  expose 
the  interior. 


thus  all  smoothed  out  and  the  vagina  appears  as  a  broad,  smooth  surface.  A 
good  way  to  let  air  into  the  vagina  before  introducing  the  speculum  is  shown 
in  Figure  19.  The  examination  is  then  best  made  by  means  of  the  writer's 
cylindrical  metal  speculum,  with  a  large  handle,  as  shown  in  Figure  20, 
which  exposes  every  part  and  protects  the  vulvar  orifice  when  treatments  are 
given. 

The  Sims'  position  (see  Figs.  21  and  22)  is  one  in  which  the  patient  lies 
semi-prone,  with  the  right  leg  drawn  a  little  above  the  left,  and  with  the  left 
arm  behind  the  back  or  hanging  over  the  edge  of  tlie  table.  The  posture 
assumed  is  one  in  which,  if  the  abdomen  were  opened,  the  pelvic  viscera  would 
be  poured  out  onto  the  table.     The  pelvis  must  be  so  disposed  at  the  edges  of 


Fig.  22. — Inteodxjcing  a  Cylindrical  Metal  Speculum  with  a  Stout  Handle  for  Examination 
AND  Treatments  in  the  Sims'  Posture. 


Fig.  23. — Patient  in  Sims'  Posture  Exaggerated  by  Decided  Elevation  or  the  Foot  of  the 
Table.     The  figure  also  shows  the  method  of  pulling  apart  the  buttocks  and  letting  air  into  the 
vagina  to  facilitate  the  introduction  of  the  Sims'  speculum. 
24 


EXAMINATION    IN    CHILDKEN. 


25 


the  table  as  to  afford  a  convenient  view  of  the  parts  when  the  speculum  is 
inserted,  with  the  perineum  retracted  and  the  vagina  ballooned  out  with  air. 
If  the  table  is  elevated  as  shown  in  Figure  23,  the  distention  of  the  vagina  is 
greater  and  a  better  view  is  often  afforded. 

Examination  in  Children. — The  examination  of  a  child  suffering  from  a 
vaginitis  is  always  easiest  to  make  in  the  knee-breast  position,  as  it  causes  no 
pain,  and  affords  a  perfect  exposure  of  the  entire  vagina  and  the  cervix, 
impossible  by  any  other  method  (see  Fig.  18).  To  make  the  examination 
entirely  painless,  the  nurse  should  slip  a  little  pledget  of  cotton  attached  to 
a  thread  saturated  with   a  ten  per  cent  solution  of  cocain  just  inside   the 


Fig.  24. — The  Examination  of  a  Child  about  Six  Years  Old,  sho"wing  the  Facility  with  which 
THE  Entire  Pelvis  can  be  Palpated  by  a  Bimanual  Rectal  and  Abdominal  Examination, 
Owing  to  the  Relatively  Large  Size  op  the  Examining  Hand. 


hymen.  Then  after  five  to  ten  minutes  the  little  patient  is  put  in  the  knee- 
breast  posture  and  the  cotton  removed,  when  the  vesical  speculum  Ko.  10  is 
introduced  and  the  vagina  at  once  balloons  out  and  can  be  seen  in  all  its 
parts  by  a  reflected  light.  It  is  usually  easy,  without  the  knowledge  of  the 
child,  to  apply  a  thorough  treatment,  say  a  five  to  ten  per  cent  solution  of 
nitrate  of  silver,  to  all  parts  of  its  walls,  or  to  insert  a  small  medi- 
cated tampon,  saturated  with,  say,  thirty  per  cent  to  fifty  per  cent  solution 
of  argyrol,  attached  to  a  fine  thread,  by  which  it  can  be  withdrawn  in  six  to 
twelve  hours. 


26 


CONSULTI^^G    KOOM    iVNB    GYNECOLOGICAL    EXAMINATION, 


When  it  is  necessary  to  make  a  careful  examination  of  the  pelvic  organs  in 
a  child,  it  is  always  best  to  do  so  at  one  sitting  and  to  make  the  examination 
thorough  by  giving  an  anesthetic.  A  few  drops  of  chloroform  is  all  that  may 
be  necessary  to  relax  the  little  patient  completely.     The  examination  should 

be  made  as  shown  in  Figure  24,  through 
the  rectum  and  lower  abdomen,  and 
never  through  the  vagina.  The  ex- 
treme simplicity  as  well  as  the  facility  of 
such  a  bimanual  recto-abdominal  examina- 
tion is  readily  appreciated  upon  noting 
that  the  hands  of  an  adult  are  relatively 
much  larger  in  proportion  to  the  pelvis 
of  a  child  than  to  that  of  an  adult.  For 
this  reason  the  pelvic  organs  in  a  child 
are  all  easily  within  reach  of  the  bi- 
manual touch. 

When  an  ovarian  tumor  is  found  in 
a  child,  it  is  usually  sarcomatous  and  de- 
mands careful  handling  on  account  of  its 
friability,  as  well  as  ]3rompt  removal  on 
account  of  its  liability  to  become  dissem- 
inated. A  large  ascitic  accumulation  in  a 
child  (see  Fig.  25),  in  the  absence  of 
any  other  evidence  of  grave  disease,  is 
apt  to  be  tubercular,  especially  in  the  col- 
ored race.  A  large  tumor  springing  from 
one  side  and  more  or  less  filling  the  pelvic 
abdomen,  is  soft  and  fluctuating,  but  not 
within  the  peritoneal  cavity,  is  generally  a 
sarcoma  of  the  kidney.  Such  tumors  have  been  observed  in  children  of  very 
tender  years. 

Examination  Standing. — It  is  important,  where  the  patient  has  a  descensus, 
or  other  displacement  of  the  pelvic  organs,  to  examine  her  in  the  erect  posture, 
as  she  stands  before  the  examiner  with  one  foot  on  a  low  stool.  In  this  way 
marked  differences  between  the  organs  in  the  dorsal  and  in  the  vertical  position 
are  often  found. 

Examination  under  Anesthesia. — It  often  happens  that  the  ordinary  digital 
and  bimanual  examination  leaves  a  doubt  as  to  the  condition  of  the  deeper 
pelvic  organs,  the  position  and  condition  of  the  body  of  the  womb,  the  uterine 
tubes,  and  of  the  ovaries.  Under  these  circumstances  it  is  always  best  to 
request  a  more  complete  and  a  deeper  examination,  with  the  patient  completely 
relaxed  by  an  anesthetic.  By  this  means  entire  relaxation  is  secured,  and 
the  resistance  which  tlie  patient  often  cannot  control  on  account  of  pain,  is 
done  away  with ;  while  at  the  same  time,  the  uterus  itself  can,  under  anes- 


FiG.  25. — A  Case  of  Tubercular  Peri- 
tonitis IX  A  Colored  Child  abou't 
NixE  Years  of  Age.  Note  the  rotund, 
ovoid,  distended  abdomen  manifestly 
due  to  an  accumulation  of  fluid  in  a  child 
not  too  ill  to  be  about. 


EXAMINATION    OF    VIRGINS.  27 

tliesia,  be  drawn  well  down  to  the  vulva  and  so  made  much  more  accessible 
to  touch.  Before  making  an  examination  under  anesthesia,  the  bowels  should 
be  well  opened,  and  the  stomach  empty.  It  is  a  good  rule  to  have  the 
patient  rest  a  day  or  two  afterwards.  The  best  anesthetic  for  such  a  pur- 
pose is  nitrous  oxide  gas.  The  gas  can  be  given  and  the  examina- 
tion made  within  three  to  five  minutes;  consciousness  follows  at  once,  and 
there  is  no  distressing  nausea  or  depression  afterwards.  Sometimes  after 
starting  the  gas,  the  patient  is  stertorous  and  does  not  relax;  a  few  whiffs 
of  ether  combined  with  the  gas  then  serve  to  produce  entire  relaxation,  after 
which  the  gas  alone  is  continued.  It  is  possible,  if  it  is  necessary,  for  a 
patient  to  get  up  within  a  few  minutes  after  such  an  examination  and  go 
home. 

Examination  of  Virgins. — Young  unmarried  women  ought,  for  decency's 
sake,  always  to  be  examined  for  the  first  time  under  an  anesthetic;  in  this 
way  their  feelings  are  spared  the  shock  and  the  distressing  ordeal,  and  the 
examination  made  is  complete  and  satisfactory,  an  exception  under  such  cir- 
cumstances without  an  anesthetic.  It  is  always  well  to  secure  permission  at 
the  same  time,  if  only  a  slight  operation  is  required,  such  as  a  dilatation 
for  dysmenorrhea,  to  proceed  with  it  at  once,  to  avoid  giving  an  anesthetic 
again. 

The  empty  rectum  is  the  one  important  avenue  of  approach  in  making  a 
deep  investigation  under  an  anesthetic.  The  finger  should  be  carried  well 
above  the  cervix  uteri,  through  the  valves,  until  the  posterior  surface  of  the 
uterus  and  of  the  left  broad  ligament  are  plainly  felt.  Too  much  force  must 
not  be  used  in  palpating;  I  have  known  several  instances  in  which  the  rectal 
wall  has  been  perforated  by  an  examining  finger,  compelling  the  examiner 
to  suddenly  and  unwillingly  turn  surgeon,  open  the  abdomen,  and  sew  up 
the  rent. 

Pain. — When  a  patient  comes  with  a  complaint  of  a  definitely  located  pain 
it  is  most  important  for  the  physician,  in  the  course  of  his  examination,  to 
discover  which  organ  is  causing  the  suffering  and  then,  by  gentle  pressure  or 
manipulations,  to  try  to  reproduce  the  pain  so  that  the  patient  may  feel  con- 
vinced that  the  source  of  her  discomfort  has  been  located,  for  if  she  can  declare 
with  conviction  that  the  pain  aroused  is  exactly  the  same  pain,  felt  in  the 
same  spot,  he  will  secure  her  hearty  cooperation  in  following  any  rational 
plan  for  her  relief.  Patients  sometimes  complain  of  pain  in  the  pelvis,  when 
a  careful  examination  shows  that  no  abnormality  can  be  detected  in  any  organ. 
Here,  as  a  rule,  the  pain  is  complained  of  whenever  any  part  of  the  pelvic 
peritoneum  or  any  pelvic  organ  is  squeezed  slightly  betwe'en  the  fingers  of  the 
two  hands.  If  this  fact  is  carefully  noted  and  remembered,  many  unneces- 
sary, often  mutilating  operations  will  be  avoided.  When  intermittent 
attacks  of  pain  arc  complained  of,  unless  the  examiner  can  dis- 
tinctly reproduce  tlie  pain  or  touch  the  very  spot,  the  patient 
ought  to  be  kept  under  observation  until  a  typical  attack  comes 


28 


CONSULTING    ROOM    AND    GYNECOLOGICAL    EXiVMINATION. 


on.  The  physician  should  be  called,  by  day  or  night,  to  make  a  careful 
investigation  as  to  the  exact  character  of  the  attack  and  the  site  of  the  sensi- 
tiveness. If  he  has  had  much  experience,  he  will  very  often  be  able  to  say 
at  once  "  the  attack  is  one  of  renal  colic,"  or  "  it  is  undoubtedly  due  to  gall 
stones,"  etc. 

The  right  side  of  the  abdomen  is  peculiar  in  that  we  find  there  a  chain 
of  at  least  five  organs,  beginning  at  the  margin  of  the  ribs  and  extending 
down  to  the  pelvic  floor,  and  some  of  the  morbid  conditions  affecting  these 
organs  are  liable  to  be  mistaken  one  for  another.  These  organs  are:  the  gall 
bladder,  the  right  kidney,  the  cecum,  the  vermiform  appendix, 
and  the  right  uterine  tube  and  ovary  (see  Fig.  26).  It  might  at 
first  sight  seem  impossible  that  anyone  familiar  with  abdominal  diseases 
could  mistake  a  disease  in  such  an  organ  as  the  gall  bladder,  for  instance, 
at  the  upper  end  of  the  chain  for  a  disease  of  the  tube  and  the  ovary 
at  its  lower  end.  Such  mistakes  have  occurred,  however,  and  that  in  the 
hands  of  some  of  our  best  diagnosticians.     The  physician  who  would  avoid 

errors  of  this  kind  must 
not  only  familiarize  himself 
vnth  the  signs  belonging  to 
the  diseases  characteristic  of 
each  of  these  organs,  he 
must  also,  in  every  case 
where  anyone  of  them  ap- 
pears to  be  affected,  exam- 
ine the  other  organs  as  well. 
The  cases  which  most  fre- 
quently give  rise  to  mistakes 
are  those  of  more  or  less 
vague,  but  persistent  pain 
in  the  right  part  of  the  ab- 
domen, whether  in  the  loin, 
or  anteriorly,  or  extending 
down  in  the  direction  of 
the  pelvis,  or  in  the  back 
below  the  crest  of  the  ilium. 
These  sufferers  may  go  the 
rounds  for  many  years  with 
no  more  definite  complaint 
than  a  vague  but  very  real 
unrest,  which  the  patient 
attributes  without  doubt  to 
"  something  wrong  in  her 
right  side,"  until  some  one  is  found  with  sufiieient  skill  to  determine  which 
link  in  the  chain  is  at  fault.     My  own  experience  has  sho^vn  me  that  over 


Fig.  26. — Shows  the  Organs   on  the  Right  Side  whose 

Affections  are  Liable  to  be  Confused  One  with  An- 
other. Bj^  careful  reetal  palpation  the  ovary  and  uterine 
tubes  are  felt;  by  careful  palpation  in  the  right  iliac  fossa  a 
diseased  appendix  can  be  reached ;  and  the  right  kidney  can 
be  examined  with  unerring  certainty  by  injecting  its  pelvis 
through  the  ureter. 


PAIN    AS    A    SYMPTOM    IN"    EXAMINATIOlSr. 


29 


sixty  per  cent  of  these  cases  of  ill  defined  right-sided  pain  are  due  to  some 
trouble  in  the  kidney,  usually  a  displacement,  with  a  kinking  of  the  ureter, 
and  retention  of  urine  in  the  renal  pelvis. 

It  is  an  easy  matter  for  anyone  experienced  in  catheterizing  the  ureters 
to  pass  a  renal  catheter  up  into  the  right  kidney,  inject  fluid  into  the  pelvis, 
and  thus  bring  on  a  mild 
attack  of  renal  colic.  The 
patient,  as  a  rule,  will  at 
once  identify  the  pain  thus 
induced,  with  the  pain  from 
which  she  has  been  suffering, 
both  as  to  situation  and  char- 
acter. The  catheter  which  is 
passed  up  the  ureter  for  the 
purpose  of  injecting  the  kid- 
ney, if  tipped  with  wax,  may 
show  scratch  marks  when  ex- 
amined under  a  lens  of  low 
magTiifying  power,  revealing 
the  presence  of  a  stone  in 
either  the  pelvis  of  the  kidney 
or  the  ureter  (see  Fig.  27). 

Backache . — -The  most  se- 
rious  mistakes  and  the  gravest 
disappointments  often  result 
from  operative  procedures  cor- 
recting retro-displacements  of 
the  uterus,  done  in  the  hope 
of  relieving  a  backache.  As 
a  matter  of  fact,  the  backache 
so  common  in  women  is  rarely 
due  to  a  displacement;   it  is 

either  an  affection  per  se  and  purely  local,  or  it  is  dependent  upon  an  anemia 
and  a  general  condition  of  ill  health  (neurasthenia).  From  backache  to  uterus 
in  women,  and  backache  to  kidneys  in  men,  is  a  fallacious  mode  of  reasoning. 
When  the  pain  is  situated  very  low  down  in  the  back,  the  coccyx  should  be 
examined  carefully  bimanually,  with  one  finger  in  the  rectum.  Occasionally, 
a  well  localized,  severe  pain  in  the  coccyx  is  relieved  by  the  extirpation  of  the 
structure,  but,  as  a  rule,  coccygeal  operations  are  failures  and  are  greatly  over- 
done, to  the  discredit  of  surgery  (see  Chap.  IX)'. 

Notes  of  Examination. — The  notes  of  the  examination'  should  always  be  care- 
fully compared  with  the  complaints  of  the  patient,  which  ought,  as  a  rule,  to 
be  written  down  in  her  own  characteristic  words ;  if  the  anatomical  findings 
do  not  tally  with  the  statements  made  by  the  sufferer,  or  afford  a  reasonable 


Fig.  27. — Examining  a  Ureteral  Catheter  that  has 
BEEN  Wax-tipped  and  Passed  through  the  Bladder 
UP  into  the  Pelvis  of  the  Kidney  and  Carefully 
Withdrawn.  The  examiner  is  using  a  lens  and  holding 
the  catheter  so  that  the  light  strikes  the  uppermost  glis- 
tening surface  as  he  turns  the  catheter  between  thumb 
and  forefinger,  while  looking  for  the  gouges  or  scratch 
marks  indicative  of  the  presence  of  a  stone  in  the  upper 
urinary  tract. 


30  CONSULTING    ROOM    AND    GYNECOLOGICAL    EXAMINATION. 

exj)lanatioii  of  tlio  complaints,  llie  examiner  should  not  rest  satisfied  imtil 
lie  lias  made  a  further  and  more  searching  investigation  and  perhaps  dis- 
covered the  cause  for  the  discrepancy  between  the  subjective  sensation  and 
the  objective  findings.  When  the  patient  comes  complaining  of  pain,  and 
the  examiner  finds  a  displacement  of  some  sort,  he  should  be  very  cautious 
about  promising  that  the  correction  of  the  displacement  will  serve  to  relieve 
the  pain.  It  will  be  safer  to  promise  nothing  more  than  a  good  mechan- 
ical result  from  the  operation,  while  expressing  the  reasonable  hope  that  the 
discomfort  will  be  relieved. 

GENERAL   PRINCIPLES   OF   TREATMENT. 

Outlining  a  Course  of  Treatment. — With  the  statements  of  the  patient  clearly 
borne  in  mind,  and  with  the  patient  before  him  and  fresh  from  the  examina- 
tion, the  gynecologist  should  be  prepared  at  once  to  outline  a  course  of  treat- 
ment. Whenever  there  is  a  lingering  uncertainty  as  to  the  condition,  a  ten- 
tative course  may  be  tried  with  a  view  of  proceeding,  if  necessary,  at  a  later 
date,  to  more  radical  procedures.  It  is  my  custom  in  puzzling  cases  to  note 
all  the  facts  ascertained  and  then  to  add  a  list  of  the  doubtful  matters  still  to 
be  determined. 

In  general,  the  lines  of  treatment  are: 

(1)  General,  hygienic. 

(2)  Palliative. 

(3)  Radical,  by  operation. 

When  in  doubt  it  is  best  to  proceed  from  the  simpler  to  the  more  serious  modes 
of  treatment.  Having  outlined  a  scheme,  the  physician  should  stick  to  it 
until  it  is  fairly  tried,  when  he  may  be  justified  in  assuming  a  more  aggressive 
course. 

If  no  local  condition  is  discovered  to  account  for  the  discomfort  complained 
of,  a  general  hygienic  course  may  be  adopted,  extending  over  a  period  of  some 
weeks  or  months. 

Hygienic  treatment  involves  these  various  factors : 

Rest. — Early  hours  in  retiring;  breakfast  in  bed;  rest  an  hour  before 
and  an  hour  after  each  meal,  or  lying  down  six  half -hours  in  each  day.  A 
splendid  rest  may  be  obtained  by  regularly  putting  on  a  night-gown  and  going 
to  bed  for  an  hour  to  an  hour  and  a  half  in  the  afternoon. 

Food. — Simple,  nourishing  food,  avoiding  pastry,  pickles,  condiments, 
and  fried  articles.  Some  easily  digested  food  betweeh  meals  and  before  going 
to  bed,  such  as  a  cup  of  milk,  malted  milk,  gruel,  or  broth. 

Exercise. — Some  exercise  must  be  taken  every  morning  and  afternoon, 
whether  in  walking,  driving,  working  in  a  garden,  or  playing  golf. 

Medicine. — A  bitter  tonic  such  as  Calisaya  bark,  or  a  pill  of  caluniba 
and  gentian,  one  grain  each.  Opium  must  never  be  given  in  any  form  to 
induce  sleep.     If  it  is  necessary  to  give  some  sedative  for  a  few  nights  in 


HYGIENIC    MEASURES    OF    TREATMENT.  31 

order  to  break  tlie  habit  of  sleeplessness,  one  of  the  milder  hypnotics  must  be 
used  (see  Chap.  VIII). 

Massage. 

Cold    morning    sponge. 

Regular    evacuations    of   the    bowels. 

Sunlight    baths. 

Often  the  mere  assurance  that  there  is  nothing  serious  the  matter  will 
send  the  patient  rejoicing  on  her  way,  ready  to  take  plenty  of  exercise,  to 
live  in  the  open  air,  to  take  her  food  with  relish,  and  to  enter  once  more  into 
natural  home  relationships.  Such  is  the  discipline  of  the  mind  over  the  feel- 
ings. I  have  many  times  seen  a  patient  walk  into  my  office  the  picture  of 
woe,  with  all  her  functions  disordered,  because  she  has  been  told  she  had  an 
incurable  disease  which  rendered  it  necessary  to  remove  her  uterus,  uterine 
tubes,  and  ovaries.  Upon  my  assuring  her  that  there  was  nothing  whatever 
the  matter  with  these  organs,  she  has  left  my  office  radiant,  a  woman  in  per- 
fect health. 

Palliative  treatments  may  be  followed  out  while  keeping  a  patient  under 
observation. 

Palliative  treatments  are  applied  by  the  vagina  in  the  form  of: 

(1)  Painting  of  the  cervix  and  vagina. 

(2)  Applications  of  caustics  to  the  cervix  and  the  uterine  cavity. 

(3)  Packs  in  the  vagina. 

(4)  Douches  in  the  vagina. 

(5)  Pessaries. 

For  painting  the  cervix  and  the  vault  of  the  vagina,  a  strong  tincture  of 
iodine  (Churchill's)  was  largely  in  vogue  a  couple  of  decades  ago.  The 
nitrate  of  silver  in  strong  solution,  ten  to  forty  j^er  cent,  may  be  used 
on  the  diseased  cervical  mucosa.  In  using  any  powerful  solutions  for 
treating  the  cervix  or  the  glands  within  the  cervical  canal  I  commonly 
employ  a  cylindrical  metal  speculum  with  a  stout  handle  like  that  shown 
in  Figure  28.  This  serves  to  isolate  the  cervix  and  to  protect  the  sur- 
rounding parts  from  the  cauterizing  effects  of  any  of  the  drugs  used.  It  is 
doubtful  if  uterine  treatments  for  "  endometritis  "  are  not  far  more  danger- 
ous than  useful.  Many  cases  of  salpingitis  have  been  set  up  in  this  way. 
Packs  support  the  uterus  and  provoke  a  watery  discharge  when  glycerin 
is  used.  They  do  not  do  much  to  cure  any  disease.  Douches  as  hot  as 
can  be  borne  often  give  much  relief;  just  how  far  they  are  curative  is  doubt- 
ful. Pessaries  are  being  more  and  more  rarely  used.  They  have  a  use- 
ful, but  limited  field.  The  question  of  their  use  is  discussed  in  detail  in 
Chapter  XIII. 

While  undergoing  a  course  of  palliative  treatment,  vaginal  packs  con- 
sisting of  cotton  and  wool  tampons  carrying  boroglycerid,  may  be  applied  to 
the  vagina  and  the  cervix;  hot  water  douches,  as  hot  as  can  be  borne 
comfortably,  say  105°— 115°  F.,  continued  for  ten  or  fifteen  minutes  once  or 


32 


COInTSTJLTIIS^Ct    EOOM    and    GYNECOLOGICAI.    EXAMINATIOlSr. 


twice  a  clay,  are  serviceable  after  removing  the  pack.  The  bowels  should 
be  kept  unloaded  bv  giving  a  flaxseed  enema,  made  by  boiling  four  table- 
spoonsful  of  the  whole  seeds  in  a  quart  of  water  for  ten  minutes,  then  strain- 
ing and  injecting  the  soothing  mucilaginous  fluid  warm.      Massage    may    be 


Fig.  28. — ExA^^xrN■G  tete  CER^^x  and  Vattlt  of  tfte  Vagixa  with  Kellt's  O-ltxdrical  Metal 
SpecultjM  with  Stout  H.andle.  This  instninient  is  most  convenient  for  exposing  the  cervix  and 
protecting  the  rest  of  the  vagina  wliile  treating  the  cer"\dx  with  canterj-,  etc. 


given  to  quicken  the  circulation  and  process  of  nutrition,    cold    or   hot   packs 
at  night  to  induce  rest,  and  a   cold   spinal   douche   in  the  morning. 

In  deciding  to  do  an  operation,  it  is  always  most  important  to  be  sure  that 
the  operation  will  relieve  the  complaint.  If  a  minor  operation  is  suggested, 
such  as  the  repair  of  a  lacerated  cervix,  the  physician  should  take  gTeat  pains 
to  determine  that  there  is  no  other  serious  affection  which  he  is  likely  to  leave 
unrelieved.  In  my  personal  experience,  the  operation  for  laceration  of  the 
cervix  is  generally  a  most  useless  gynecological  procedure,  often  unnecessarily 
performed.  It  is  often  recommended  when  the  patient  is  in  reality  suffering 
from  a  uterine  displacement  associated  with  a  broken  down  vaginal  outlet, 


EXAMINATION    OF    RECTUM.  33 

and  sometimes  even  in  the  jDresence  of  a  grave  iniiammatory  trouble  involving 
tlie  uterine  tubes, 

EXAMINATION   OF  RECTUM. 

The  rectum,  owing  to  its  proximity  to  the  other  pelvic  organs,  and  its 
frequent  association  with  many  of  their  diseases,  is  as  much  a  part  of  the 
field  of  the  gynecologist  as  are  the  organs  lying  in  front  of  the  vagina  and 
uterus,  namely  the  urethra  and  the  bladder.  The  specialist  or  the  general 
practitioner,  who  fails  in  his  gynecological  examinations  to  take  the  rectum 
constantly  into  account,  will  often  in  this  way  lose  important  opportunities 
to  make  a  correct  diagnosis.  It  is  only  necessary  to  recall  the  close  anatomical 
connection  of  the  rectum  with  the  perineum,  with  the  vagina,  and  with  the 
cervix,  as  well  as  its  constant  contact  with  the  body  of  the  uterus  and  the  left 
uterine  tube  and  ovary,  to  realize  that  these  claims  are  not  exaggerated.  The 
wonder  is  not  that  the  rectum  is  so  often  involved,  but  that  lying  as  it  does, 
it  does  not  more  frequently  enter,  as  an  important  complication,  into  a  great 
variety  of  gynecological  ailments.  The  rectum  is  of  interest  to  the  gynecol- 
ogist in  the  following  ways: 

(1)  It  may  itself  be  the  cause  of  diseases  of  the  pelvic  structures,  as  when 
a  carcinoma  of  the  rectum  extends  to  the  vagina,  or  the  uterus,  or  the  pel- 
vic peritoneum.  The  constant  overloading  of  the  rectum  often  causes  stasis 
of  the  pelvic  vessels,  and  either  through  this  means  or  through  the  attendant 
toxemia,  is  a  common  cause  of  dysmenorrhea.  In  children,  a  form  of  pruritus 
is  occasioned  by  the  escape  of  thread  worms  from  the  rectum  out  onto  the  vulva. 

(2)  The  rectum  is  liable  to  be  affected  in  its  turn  by  diseases  of  the  pelvic 
organs;  for  example,  it  may  be  choked  by  a  large  uterine  fibroid,  if  it  is 
one  large  enough  to  choke  the  pelvis  which  has  been  caught  under  the  promon- 
tory of  the  sacrum;  or  again  it  may  be  pressed  upon  by  ovarian  tumors;  or 
its  lumen  may  be  invaded  by  pelvic  abscesses. 

Almost  all  cases  of  extensive  pelvic,  that  is  to  say  uterine  tubal 
inflammatory  disease,  involve  the  rectum  as  well  as  the  adjacent  struc- 
tures; extensive  disease  in  the  pelvic  cellular  tissue  may  choke  the 
lumen  of  the  bowel  at  the  pelvic  floor  down  to  the  size  of  the  little  finger.  A 
vicious  retroflexion  may  cause  obstinate  constipation,  as  in  the  earliest 
and  now  classical  case  observed  by  Koberle.  Large  pouting  hemor- 
rhoids may  be  only  a  sign  of  a  blockade  in  the  pelvic  circulation,  induced  by 
inflammatory  masses  at  mid. pelvis.  Further,  we  have  but  to  recall  the  cases 
of  complete  septal  tear,  extending  from  the  vagina  into  the  bowel  and  ruptur- 
ing one  or  both  sphincters. 

(3)  Diseases  of  the  rectum  are  sometimes  mistaken  for  uterine  or 
ovarian  diseases.  This  error  is  a  grave  one,  inasmuch  as  mutilating 
operations  may  be  and  have  been  performed  on  the  innocent  genital  organs, 
when  the  disease  actually  lay  within  the  rectum.  Hemorrhoids  produce  a 
bearing  down  sensation,  easily  mistaken  for  the  bearing  down  caused  by  a 


34  consultinct  room  aistd  gynecological  examination. 

displacement  of  the  uterus;  a  cancer  of  the  rectum,  high  up,  has  been 
repeatedly  mistaken  for  a  pelvic  tumor  of  some  other  kind ;  and  most  im])ortant 
of  all,  a  proctitis,  with  its  j^elvic  distress  and  vague  pains  is  commonly 
overlooked  or  mistaken  for  chronic  disease  of  the  ovaries  and  tubes.  I  recall 
also  in  this  conection  the  cases  so  much  talked  about  a  generation  ago,  where 
a  fissure  of  the  rectum,  causing  pains  reflected  to  other  parts  of  the 
pelvis,  was  often  mistaken  for  uterine  or  ovarian  disease. 

It  is  manifestly  important  for  all  these  reasons  that  the  gynecologist  should 
include  the  rectum  and  its  diseases  within  the  scope  of  his  inquiry  in  almost 
every  case,  and  further  that  he  should,  if  necessary,  be  ready  to  apply  the 
appropriate  treatment.  I  would  lay  great  stress  then  upon  the  rou- 
tine examination  of  the  rectum.  I  have  no  doubt  at  all  that  in  every 
hundred  cases  examined  in  this  way  by  one  who  has  newly  taken  up  the  sub- 
ject, a  number  of  surprising  discoveries  will  be  made. 

The  reason  for  the  neglect  of  this  field  in  the  past  has  lain  in  the  difficult 
and  unsatisfactory  character  of  the  examinations,  which  elicited  no  positive 
information.  Even  recently,  the  method  in  vogue  has  been  to  investigate  the 
diseases  of  the  rectum  situated  above  the  anal  margin  with  the  index  finger, 
which  at  best  cannot  do  more  than  reveal  a  few  of  the  gross  changes.  A  dis- 
tinguished proctologist  and  author  of  a  large  work  on  rectal  diseases  once 
declared  at  a  large  society  meeting  at  St.  Louis,  that  he  had  no  interest  in 
diseases  of  the  rectum  that  did  not  manifest  themselves  to  his  educated  touch ! 
Concurrently  with  the  finger  examinations,  various  thin-bladed  bivalve  and 
trivalve  specula  were  used,  in  the  vain  hope  of  seeing  as  well  as  feeling  some- 
thing; but  these  little  instruments  were  in  reality  almost  wholly  useless,  for 
they  did  little  more  than  expose  the  sphincter  area,  and  as  much  of  the  bowel 
above  as  might  prolapse  between  the  narrow  blades  of  the  speculum.  It  was 
with  rectar  diseases  as  with  eye  diseases  a  few  decades  ago,  when  the  patient 
had  either  amblyopia  or  amaurosis ;  in  amblyopia  the  patient  saw  nothing,  but 
the  physician  saw  something,  while  in  amaurosis  neither  patient  nor  physician 
saw  anything.  Several  men,  such  as  Sims  and  J.  G.  Carpenter,  had  looked 
into  the  rectum,  using  a  Sims'  speculum  in  a  Sims'  or  an  elevated  posture, 
but  the  action  was  incidental,  and  they  never  appreciated  the  value  of  the 
method  enough  to  advertise  it  or  insist  upon  its  universal  acceptance  as  the 
one  method  of  the  highest  importance,  and  so  fundamental  and  absolutely 
necessary  in  all  satisfactory  examinations  and  treatments  of  the  rectum  above 
the  sphincters.  ISTo  other  person  took  particular  note  of  their  use  of  the  Sims' 
speculum  in  this  way  and  nothing  was  accomplished.  One  insuperable  added 
difficulty  was  the  want  of  a  proper  instrument  to  make  a  thorough  investiga- 
tion of  the  bowel,  for  the  Sims'  speculum  is  but  a  make-shift.  I  took  up  this 
subject  in  the  eighties,  while  yet  in  Philadelphia,  and  in  April,  1895,  I  pub- 
lished an  article  in  the  Annals  of  Surgery  (vol.  21,  p.  468),  in  which  I 
insisted  upon  the  importance  as  well  as  the  entire  feasibility  of  always  exam- 
ining the  rectum  in  an  elevated  posture  under  air  distention,  using  a  long 


METHOD    OF    RECTAL    EXAMINATION. 


35 


eylindrical  speculum  with  a  large  handle,  which  I  devised  especially  for  this 
purpose. 

Method  of  Examination  (see  i'ig.  29). — A  good  single  speculum  for  gen- 
eral use  for  this  purpose  is  one  fourteen  centimetres  long  and  twenty -two 
millimetres    in   diameter    (5^  X  f    in.).      A   serviceable    long    proctoscope    is 


Fig.  29. — Rectal  Instruments.     Four  specula  of  different  sizes,  a   conical  dilator  for  dilating  the 
sphincter,  and  long  alligator  forceps  for  conveying  cotton  or  gauze  high  up  into  the  rectum. 

twenty  centimetres  long,  and  a  sigmoidoscope  may  be  used  which  is  thirty 
centimetres  in  length  or  even  more.  The  handle,  from  ten  to  thirteen  centi- 
metres in  length,  affords  a  strong  grasp  for  the  fist.  The  obturator  of  the 
speculum  must  not  be  pointed,  nor  yet  too  blunt.  Aside  from  the  speculum,  the 
following  instruments  are  needed:  A  head  mirror  to  reflect  an  electric  light, 
gaslight,  lamplight,  or  daylight ;  a  long  pair  of  alligator  forceps  used  in  swab- 
bing out  the  bowel.  The  bowel  ought  to  be  empty  when  the  patient  assumes 
the  knee-breast  posture,  having  laid  aside  all  constricting  articles  of  dress,  espe- 


36 


CONSTJLTIiN^G    ROOM    AiS^D    GYISrECOLOGICAL    EXAMIXATIOTs^. 


cially  corsets  and  articles  likely  to  Lind  the  cliest  aiKl  limit  tlie  tendency  of 
the  viscera  to  gravitate  towards  the  diaphragm.  The  end  of  the  speculum  is 
now  well  oiled  and  introduced  by  thrusting  it  in  a  direction  slightly  down- 
wards and  into  the  pelvis  through  the  anal  orifice  (see  Fig.  30).  A  good 
way  to  effect  its  introduction  is  to  push  it  a  little  way  into  the  anus,  and  then 
quickly  withdraw  it,  when  the  anal  orifice  at  first  contracts  vigorously  and 
then  relaxes ;  now  in  the  act  of  relaxation,  the  bowel  is  caught  by  surprise,  as 
it  were,  and  the  speculum  thrust  quickly  in  before  another  contraction  can 
take  place.  As  soon  as  the  speculum  enters  about  two  inches,  its  deeper  intro- 
duction into  the  bowel  beyond  should  be  conducted  under  the  guidance  of  the 
eye,  looking  down  its  liunen  into  the  bowel  (see  Fig.  31).  Only  those  who 
have  a  large  experience  in  carrying  the  specuhun  into  the  upper  bowel  ought 
ever  to  make  the  attempt  to  push  it  on  up  the  bowel  without  removing  the 
obturator  and  watching  each  step  in  the  advance.     With  the  removal  of  the 


Fig.  30. — Shows  the  Method  of  Ixtroditcixg  the  Loxg  Rectal  SPEcrxmi  for  the  Purpose 

EXAMIXING    the    ExTIRE    LeX-GTH    OF    THE    Lo'U'ER    BoWEL. 


obturator,  the  air  rushes  in  with  a  distinct  suction  sound  and  distends 
the  rectal  canal :  at  times  it  does  so  suddenly,  at  other  times  slowly  step  by 
step,  until  the  air  expansion  reaches  up  to  the  hollow  of  the  sacrum,  to  the 
promontory  of  the  sacrum,  and  even  beyond  it  into  the  sigmoid.  I  thought 
in  my  first  efforts  that  I  could  look  well  up  into  the  descending  colon,  where 


METHOD    OF    KECTAL    EXAMINATION. 


37 


I  could  feel  the  end  of  the  speculum  through  the  abdominal  wall,  apparently 
not  far  from  the  ribs.  In  this,  however,  I  was  misled,  and  I  have  not  yet 
been  able  to  use  a  colonoscope.  As  the  light  reflected  by  the  head  mirror  is 
directed  into  the  bowel,  the  ampulla  is  first  seen  and  the  sharp-edged  over- 
lapping valves  which  limit  it  just  above  on  the  right  and  the  left.     With  the 


Fig.  31. — Shows  the  Inspection  of  the  Bowel  with  a  Simple  Head  Mirror  Using  a  Reflected 

Electric  Light. 

illumination  properly  directed,  the  examiner  will  easily  keep  the  instrument 
well  within  the  lumen  of  the  bowel  so  as  not  to  cut  .the  mucosa,  as  he  carries 
it  successively  higher  and  higher  until  the  uppermost  limit  of  expansion  is 
reached.  Oftentimes  this  upper  limit  is  marked  by  a  little  puckered  depres- 
sion in  the  midst  of  a  series  of  concentric  folds.  It  is  important  not  to  mis- 
take this  normally  contracted  empty  bowel  for  a  stricture  of  the  rectum  or  of 
the  sigmoid.  The  soft  margins  of  the  normal  lumen  at  this  point  can  readily 
be  examined  Math  a  metal  instrument,  a  searcher,  or  a  scoop,  or  by  pushing 
up  a  large  soft  catheter.  It  is  well,  in  the  course  of  the  examination,  to 
notice  and  to  touch  the  promontory  and  the  hollow  of  the  sacrum  against  which 
the  distended  bowel  closely  applies  itself.  As  the  instrument  is  gradually 
withdrawn,  the  character  of  the  mucosa  on  all  sides  is  noted,  its  natural  red- 
ness, the  vessels  which  course  like  streams  and  subdivide  into  lesser  and  lesser 


38  CONSULTING  ROOM  AND  GYNECOLOGICAL  EXAMINATION. 

tributaries,  sometimes  tiny  little  points,  the  openings  of  glands  are  visible,  the 
valves  are  each  noted  with  particular  care,  they  may  be  extensively  over- 
lapping, making  the  bowel  tortiions,  or  have  thickened,  inflamed  margins  or  be 
almost  obliterated.  The  signs  of  rectal  inflammation  are  evident  in  a  diffuse 
haziness  or  velvety  appearance  of  the  mucosa,  associated  with  the  disappear- 
ance of  the  normal  vascularization,  and  often,  although  the  tissues  bleed  easily, 
no  vessels  at  all  can  be  seen;  old  inflammatory  trouble  often  leaves  behind 
patches  of  brownish  discoloration  seen  mottling  the  mucosa  everywhere ;  ulcers 
are  always  plainly  visible ;  polyps  are  readily  seen  pendant  in  the  lumen,  and 
occasionally  the  ragged,  bleeding,  granulating  surface  of  a  carcinoma  fills  the 
lumen  and  forbids  the  further  introduction  of  the  speculum.  When  the  bowel 
is  strictured  by  syphilis,  by  tuberculosis,  or  by  early  cancer,  one  can  often  use 
a  smaller  speculum  with  advantage,  one  about  twelve  or  fifteen  millimetres  in 
diameter.  It  is  important  in  such  cases,  when  it  can  be  done  without  risk, 
to  carry  the  speculum  above  the  diseased  area  to  discover  the  healthy  bowel 
above,  and  so  to  determine  the  extent  of  the  disease.  For  the  examination  of 
the  hemorrhoidal  region,  a  shorter  speculum,  four  centimetres  long,  which  I 
call  a  sphincteroscope,  is  of  value.  The  mucosa  of  the  bowel  prolapses  into 
this  on  withdrawing  the  obturator,  and  the  hemorrhoids  swell  up.  It  is  of 
an  occasional  advantage  to  have  a  sphincteroscope  made  with  a  fenestra  on 
one  side  about  two-fifths  of  an  inch  in  diameter,  cut  through  the  entire  length 
of  the  tube.  This  allows  any  diseased  tissues  within  the  sphincter  area  to 
drop  into  the  lumen  for  examination  and  treatment.  With  the  sphincteroscope 
one  also  sees  fistules  and  fissures  to  better  advantage. 

Methods  of  Treatment  of  Rectal  Diseases. — It  does  not  lie  within  the  scope 
of  my  undertaking  to  do  more  than  to  touch  upon  this  important  special  branch, 
so  closely  allied  to  the  gynecological  field.  The  following  are  some  of  the 
general  guiding  principles;  the  bowel,  which  has  been  thoroughly  evacuated 
beforehand,  can  be  well  cleansed  with  pledgets  of  cotton  dipped  in  warm  boric 
acid  solution  and  introduced  by  means  of  the  long  alligator  forceps  (see  Fig. 
32).  An  application  is  in  like  manner  readily  made  to  ulcers  by  means  of 
cotton  pledgets,  saturated  with  a  two  or  a  five  per  cent  silver  solution;  this 
can  be  done  with  as  much  accuracy  as  in  the  treatment  of  a  sore  throat. 
Inflamed  areas  in  the  upper  bowel  can  be  treated  by  packing  with  gauze  carry- 
ing a  ten  per  cent  ichthyol  solution  in  water  and  glycerin.  A  cotton  bolus 
makes  a  good  pack  too.  These  packs  thus  applied  to  the  upper  bowel,  or  to 
the  whole  bowel  from  the  sigmoid  down,  can  be  left  in  place  until  they  are 
passed  in  the  course  of  nature  by  the  patient. 

When  maligTiant  disease  is  discovered,  it  is  easy  with  a  pair  of  cutting 
sharp-edged  forceps,  with  short  jaws  working  like  alligator  forceps,  to  remove 
a  piece  of  the  tissue  for  microscopic  examination. 

In  the  treatment  of  fissure,  it  is  sufficient  to  give  the  patient  enough  gas 
to  make  her  unconscious,  and  to  use  the  conical  dilator  (see  Fig.  29,  p.  35), 
so  as  to  thoroughly  overstretch  the  sphincter  area  until  the  tips  of  five  fingers 


METHOD  OF  TREATMENT  BY  RECTUM.  39 

can  be  introduced.     This  can  also  be  done  with  two  Sims'  specula,  one  a  little 
narrower  than  the  other,  introduced  together  and  then  separated  widely,  also 


Fig.  32. — Using  the  Alligator  Forceps  holding  Pledget  op  Cotton  to  Touch  or  Cleanse  a  Por- 
tion OF  the  Upper  Bowel. 

effecting  a  thorough  dilatation.  In  some  cases  it  is  well  to  make  light  longi- 
tudinal cuts  with  a  scalpel  through  the  base  of  a  fissure,  so  as  to  divide  the 
superficial  sphincter  fibres. 


CHAPTER    II. 

HYGIENE   OF  INFANCY  .\ND   GIRLHOOD. 

(1)  Hygiene  of  infancy  and  childhood:  General  considerations,  p.  40.     Causes  of  infant  mortality 

and  ill-health  among  children,  p. '41.  Remedial  measures — Education  of  mother,  p.  41; 
public  hygiene,  p.  44;  water  supply  and  disposal  of  sewerage,  p.  44;  clean  air,  p.  44; 
public  control  of  milk  supply,  p.  44;  improvement  of  housing  conditions,  p.  45;  pub- 
lic parks,  etc.,  p.  49;  protection  against  infectious  diseases,  p.  50.     Summary-,  p.  51. 

(2)  Hygiene  of  the  school  girl:  School-going  age,  p.  51.     Hygienic  habits,  p.  52.     Physical  con- 

dition, p.  54.  Condition  of  eyes,  p.  56.  Condition  of  ears,  nose,  and  throat,  p.  57. 
School-building  and  appliances,  p.  58.  Physical  training  and  medical  gj-mnastics,  p.  59. 
School  Hfe  in  relation  to  puberty,  p.  65.     Summar\',  p.  67. 

(3)  Hygiene  of  puberty  and  of  occupation:  Hygiene  of  puberty — Nutrition,  p.  67;  exercise,  p. 

68;  rest  and  sleep,  p.  68;  emplo\TQent.  p.  69;  bathing,  p.  69;  clothing,  p.  70;  instruction 
in  physiology'  of  reproduction,  p.  72;  hygiene  of  menstruation,  p.  72.  Hygiene  of  oc- 
cupation— Industrial  life,  p.  74;  social  life,  p.  76;  college  hfe,  p.  76. 

HYGIENE    OF    INFANCY    AND    CHILDHOOD. 

G-eneral  Considerations. — The  most  important  factor  in  the  development  of 
a  healthy  girl  baby  into  a  healthy  yonng  woman  is  an  intelligent  mother,  and 
no  more  nrgent  problem  calls  for  solution  to-day  than  that  of  securing  adequate 
training  for  the  duties  of  maternity.  Maternal  instinct  and  maternal  love  plus 
family  traditions  are  not  sufficient  equipment  for  rearing  a  healthy  family. 
They  must  be  guided  by  maternal  intelligence,  vhile  maternal  intelligence,  in 
its  turn,  must  be  aided  and  supplemented  by  a  broad  and  enlightened  public 
health  policy.  The  care  of  the  health  of  the  groving  girl  begins 
vith   the   education   of   her   mother. 

It  is  not  necessary  at  present  to  multiply  text  books  for  teaching  medical 
students  and  practitioners  elementary  facts  concerning  the  hygiene  of  infancy 
and  childhood.  Medical  literature  is  rich  in  material  easily  available  for 
instruction.  On  the  scientific  side  there  is  pretty  general  agTcement  as  to  the 
hygienic  measures  vhich  ^vhen  applied  in  the  family  and  in  the  community 
"will  preserve  and  promote  the  health  of  infants  and  children.  The  medical 
profession  has  the  knowledge  necessary  to  decrease  enormously  the  death  rate 
of  infants  and  children,  and  at  the  same  time  to  increase  proportionally  the 
average  of  health.  What  it  lacks  is  the  power  to  apply  this  knowledge,  because 
it  has  not  control  of  the  necessary  agencies.  The  remedial  measures  in  ques- 
tion are  entirely  those  of  preventive  medicine,  and  they  require  the  cooperation 
of  educational  and  social  forces,  the  formation  of  public  opinion,  legislative 
enactment,  and  administrative  control. 
40 


CATJSES    OF    INFANT    MORTALITY    AND    ILL-HEALTH    AMONG    CHILDKEN.  41 

Causes  of  Infant  Mortality  and  of  Ill-health  among  Children. — It  is  estimated 
that  of  all  children  born  into  the  world  eightj-five  to  ninety  per  cent  are  healthy 
at  birth,  and  excluding  mortality  in  infants  resulting  from  immaturity,  mal- 
formations, and  injuries  of  parturition,  the  high  death  rate  among  infants, 
as  well  as  much  of  the  physical  deterioration  of  the  growing  child,  is  directly 
traceable  to  external  and,  therefore,  controllable  causes.  In  his  testimony 
before  the  English  Interdepartmental  Committee  on  Physical  Deterioration, 
Dr.  Eicholz,  H.  M.  Inspector  of  Schools,  says,  "  Other  than  the  well-known 
specifically  hereditary  diseases  which  affect  poor  and  well-to-do  alike,  there 
appears  to  be  very  little  real  evidence  on  the  pre-natal  side  to  account  for  the 
widespread  physical  degeneracy  among  the  poorer  population.  There  is  accord- 
ingly every  reason  to  anticipate  rapid  amelioration  of  physique  so  soon  as 
improvement  occurs  in  external  conditions,  particularly  as  regards  food,  cloth- 
ing, overcrowding,  cleanliness,  drunkenness,  and  the  spread  of  common  prac- 
tical knowledge  of  home  management.  In  fact,  all  evidence  points  to  active 
rapid  improvement,  bodily  and  mental,  in  the  worst  districts,  as  soon  as  they 
are  exposed  to  better  circumstances,  even  the  weaker  children  recovering  at  a 
later  age  from  the  evil  effects  of  infant  life." 

So  long  as  a  community  can  rest  content  in  the  belief  that  a  large  infant 
mortality  is  the  natural  method  of  ridding  the  race  of  the  unfit,  the  doctrine 
of  laissez-faire  can  be  accepted  with  tolerance.  If,  however,  it  seems  probable 
that  the  influence  of  environment  must  be  reckoned  as  a  greater  cause  of  infant 
mortality  and  of  physical  unfitness  than  the  influence  of  heredity,  it  may  be 
wiser  for  society,  as  it  certainly  will  be  easier,  to  preserve  the  lives  and 
health  of  the  children  born  than  to  stimulate  an  increase  in  a  birth  rate  now 
diminishing.  As  it  is  an  open  question  whether  the  race,  as  a  whole,  suffers 
mental  or  physical  deterioration  from  a  diminished  rate  of  production  among 
the  superior  stocks,  it  is  unquestionably  a  matter  of  public  policy  as  well  as 
of  common  humanity  that  conditions  of  living  in  communities  should  be  made 
favorable  to  the  preservation  of  the  life  and  health  of  all  infants  and  children. 

Remedial  Measures  Demand  Activities  of  Public  Hygiene  and  of  Personal 
Hygiene.- — Malnutrition,  due  to  insufficient  or  improper  food,  and  infec- 
tions are  the  greatest  causes  of  infant  mortality  and  of  physical  deterioration 
in  the  growing  child.  These  causes  have  their  origin  in  poverty,  igno- 
rance, neglect,  lack  of  cleanliness,  lack  of  protection  from  sources 
of  infection,  and  lack  of  proper  education  of  the  child.  Each  one  of 
these  sources  of  evil  has  a  public  as  well  as  a  private  aspect,  and  thus  their 
removal  involves  activities  of  the  State  as  well  as  of  the  individual.  The  great 
function  of  the  physician  in  hygiene  is  to  instruct  and  to  guide  his  individual 
patients,  and  to  direct  and  lead  all  those  movements  for  social  reform  that 
aim  to  improve  conditions  of  hygienic  living.  In  modern  preventive  medicine 
the  family  physician  assumes  renewed  importance  and  dignity. 

Education  of  Mother  Essential. — It  is  interesting  to  note  in  cur- 
rent medical  literature  the   practical   unanimity   with  which   podiatrists   are 


42  HYGIENE    OF    IXFANCT    AST)    GIRT.IIOOD. 

demanding  that  women  mnst  be  educated  for  maternity,  and  this  whether  the 
podiatrist  works  mainly  with  the  poor  and  ignorant,  or  with  the  ignorant  and 
Avell-to-do.  Dr.  Hollopeter,  in  his  presidential  address  before  the  annual  meet- 
ing of  the  American  Society  of  Podiatrists  (1905),  says,  "  A  troublesome 
obstacle  that  the  pediatrist  encounters  to-day  is  the  general  ignorance  and 
helplessness  of  the  young  mother.  .  .  .  Instruction  in  the  details  of  the  baby's 
care,  and  proper  guidance  in  the  study  of  home  modification  of  milk  is  often 
the  main  function  of  the  medical  attendant,  and  a  maternal  mind  previously 
prepared  in  hygienic  instruction  is  a  great  help."  Of  interest,  too,  is  the 
insistence  with  which  thoughtful  women  are  demanding  that  the  education  of 
girls  shall  include  some  efiicient  training  for  the  duties  of  family  life.  The 
numerous  papers  of  Mrs.  Ellen  H.  Richards,  Mrs.  Mary  Hinman  Abel,  and 
others,  with  the  discussions  found  in  the  proceedings  of  the  Home  Economic 
Conferences  at  Lake  Placid,  represent  the  trend  of  educated  opinion  and  effort 
iij  this  direction. 

There  seems  to  be  general  agreement  among  physicians  and  social  reformers 
as  to  the  necessity  of  giying  all  women  some  systematic  training  for  home- 
making;  there  is  a  fair  ag-reement  as  to  the  essentials  of  such  training;  but 
the  methods  by  which  all  actual  and  potential  mothers  may  receiye  instruc- 
tion adapted  to  their  particular  needs  have  not  yet  been  deyised.  In  recent 
years  courses  in  the  household  arts,  cooking,  sewing,  etc.,  haye  been  introduced 
into  many  schools  in  this  country ;  school  physiology,  too,  has  been  widely 
included  in  public  school  curricula,  as  a  result  of  temperance  agitation,  but 
it  cannot  be  said  that  the  teaching  has  been  adequate  or  effectual.  The  value 
of  any  such  courses  for  yoimg  children  is  extremely  doubtful.  Experience  has 
shown  that  if  the  teaching  of  these  subjects  is  to  be  of  real  value,  it  must  be 
brought  very  near  to  the  period  when  the  knowledge  and  skill  acquired  are  to 
be  practically  applied  by  the  individual  in  her  o^vn  household. 

The  English  Interdepartmental  Commission  on  Physical  Deterioration 
recommends,  in  addition  to  courses  in  higher  schools,  the  establishment  of  con- 
tinuation classes  for  instruction  in  domestic  science,  at  which  the  attendance 
of  working  girls  and  others  who  have  left  school  at  an  early  age  should  be 
made  obligatory  twice  a  week  during  certain  months  of  the  year.  "  The  course 
of  instruction  at  such  classes  should  cover  every  branch  of  domestic  hygiene, 
including  the  preparation  of  food,  the  practice  of  household  clean- 
liness, the  tendance  and  feeding  of  young  children,  the  proper 
requirements  of  a  family  as  to  clothing,  everything  in  short  that 
would  equip  a  young  girl  for  the  duties  of  a  housewife." 

Training  of  the  kind  here  suggested,  gi^-cn  at  a  proper  age  and  in  an 
efficient  way  by  teachers  specially  prepared  for  the  work,  will  doubtless  even- 
tually be  made  part  of  the  compulsory  education  of  girls  in  our  public  schools. 
This  will  come  when  the  puldic  mind  fully  grasps  the  idea  that  a  nation's 
welfare  depends  as  much  upon  the  physical  efficiency  of  its  citizens  as  upon 
their  general  intelligence. 


EDUCATIOlSr    OF    MOTHER.  43 

Whatever  scheme  is  finally  adopted  for  the  universal  education  of  mothers, 
it  is  clear  that  instruction  must  be  given  to  some  classes  of  women  in  their 
own  homes  under  medical  and  sanitary  supervision.  There  is  at  present  in 
this  particular  field  of  preventive  medicine  great  opportunity  for  private  initia- 
tive through  philanthropic  effort.  The  work  of  the  various  Instructive  Visit- 
ing ]^urses'  Associations  and  similar  organizations  in  our  large  cities  has 
already  demonstrated  how  quickly  health  conditions  in  the  homes  of  the  poor 
can  be  imjDroved  as  a  result  of  sympathetic  instruction.  What  it  is  now  pos- 
sible to  give  in  cities  to*  the  very  poor  should  be  available  everywhere  for 
women  of  the  better  classes.  There  is  need  for  a  new  class  of  health  officials — 
women  trained  especially  in  dietetics  and  the  general  care  of  children  whom 
physicians  could  send  to  their  private  patients  to  instruct  them  and  help  them 
in  keeping  children  well,  as  they  now  use  trained  nurses  in  the  care  of  the  sick. 

In  this  connection  a  study  of  the  foundation  and  results  of  Dr.  Pierre- 
Budin's  "  Consultations  for  ISTurslings  "  should  be  familiar  to  all  physicians 
having  the  care  of  women  and  children.  "  Every  medical  man,"  Prof.  Budin 
says  in  his  lectures,  "  ought  to  regulate  the  feeding  of  all  infants  born  under 
his  charge.  The  lying-in  period  being  accomplished,  he  considers  his  respon- 
sibilities at  an  end  and  leaves  the  poor  woman  to  her  own  devices  in  rearing 
her  child.  She  is  expected  to  have  an  intuitive  knowledge  of  infant  feeding. 
She  might  as  well  be  expected  to  conduct  her  own  confinement.  With  proper 
direction  the  safety  of  almost  every  infant  can  be  ensured,  and 
diarrhea,  marasmus,  rickets,  and  other  dietetic  diseases  ban- 
ished from  the  community."  Prof.  Budin's  "Consultations"  are  held 
for  both  free  patients  and  for  those  who  can  pay.  They  are  really  classes  for 
the  instruction  of  pregnant  women  and  mothers  of  young  infants.  Among 
other  results  he  has  been  able  to  show  that  the  function  of  lactation  is  not 
disappearing  among  women,  but,  on  the  contrary,  the  great  majority  of  women, 
by  proper  food  and  hygienic  care  during  pregnancy,  are  able  subsequently  to 
nurse  their  children.  It  can  easily  be  imagined  that  a  rapid  hygienic  trans- 
formation, public  and  private,  could  be  made  in  any  given  locality  if  every 
physician  who  delivered  a  woman  should  be  held  responsible  for  the  infant's 
life  and  health  during  its  early  years.  Practitioners  themselves  would  quickly 
acquire  a  better  knowledge  of  dietetics  and  the  relation  of  food  to  health  and 
growth.  They  would  promptly  devise  some  method  of  effectively  educating 
mothers  and  nurses  to  whom  the  care  of  young  children  is  directly  committed. 

When  medical  inspection  of  public  school  children  becomes  an  accepted 
policy  for  all  public  scliools  of  all  gTades,  it  will  be  easy  to  foresee  the  possi- 
bility' of  an  extension  of  the  system  to  include  an  inspection  of  children  before 
the  school-going  age.  Mrs.  Parsons  in  "  The  Family "  already  suggests,  in 
addition  to  the  training  of  girls  of  all  economic  classes  in  the  care  of  young 
children,  a  system  of  State  supervision  of  the  home  education  of  actual  and 
potential  public  school  children,  by  an  extension  of  the  functions  of  the  medical 
inspectors  of  schools  and  school  nurses.      The    school    nurse    who  follows 


44  HYGIENE    OF    INFANCY    AND    GIRLHOOD. 

school  children  to  their  homes  has  already  demonstrated  that  improved  hygienic 
conditions  for  the  younger  children  may  be  expected  when  mothers  are  given 
sanitary  instruction  in  their  homes. 

Public  Hygiene. — Ability  to  obtain  food,  and  "intelligent 
mothering"  are  primary  essentials  in  maintaining  the  life  and  preserving 
the  health  of  infants  and  children,  but  they  are  not  sufficient.  Only  by  the 
aid  of  the  community  or  of  the  State  can  the  home  secure  a  pure  and  suf- 
ficient water  supply  ;  efficient  removal  of  sewage  and  garbage  ; 
pure  and  clean  food,  including  pure  clean^  milk,  and  clean  air; 
proper  housing  conditions  ;  and  protection  from  infectious 
diseases. 

The  last  fifteen  years  have  witnessed  a  great  awakening  in  our  country  to 
the  dependence  of  the  individual  health  upon  public  sanitary  measures.  Object 
lessons  there  are  in  plenty  demonstrating  the  ability  of  preventive  medicine 
to  diminish  mortality  and  morbidity,  if  trained  health  officials  are  vested  with 
necessary  power.  It  is  only  necessary  to  mention  Havana  and  Panama.  In 
ISTew  York  City,  infant  mortality  has  been  decreased  fifty  per 
cent  in  twelve  years  by  an  improvement  in  public  hygienic  con- 
ditions. 

Water  Supply  and  Disposal  of  Sewage. — Education  regarding  the 
relation  of  the  public  health  to  a  pure  water  supply  and  efficient  disposal  of 
sewage  has  gradually  secured  for  urban  communities  in  this  country  satisfac- 
tory efforts  towards  proper  conditions,  but  much  remains  to  be  done  before 
this  can  be  said  of  small  communities.  The  demonstration  of  the  relation  of 
flies  and  other  insects  to  infectious  diseases  gives  increased  imjDortance  to  the 
necessity  for  proper  disposal  of  human  excreta.  Better  protection  of  water 
supply  or  efficient  purification,  with  sanitary  disposal  of  sewage,  are  reforms 
widely  needed  in  suburban  places. 

Clean  Air. — The  pollution  of  the  air  with  smoke  and  dust,  and  the 
methods  of  street  cleaning,  or  the  lack  of  it,  have  a  very  direct  effect  upon 
the  health  of  children.  The  dangers  from  dust  are  greater  for  them  than  for 
the  adult,  both  because  they  have  less  power  of  resistance  to  many  infectious 
diseases,  and  because  their  habits  of  play  and  their  low  stature  bring  the 
entrance  to  the  respiratory  apparatus  nearer  the  floor  and  the  street. 

Public  Control  of  Milk  Supply. — Efforts  to  secure  pure  and  clean 
milk  have  not  kept  pace  with  medical  knowledge  of  its  relation  to  the  health 
of  infants  and  children.  In  the  last  few  years,  mainly  through  the  efforts  of 
the  medical  j^rofession,  it  has  become  possible  for  the  well-to-do  in  most  large 
cities  of  the  United  States  to  obtain  pure,  clean  milk,  usually  an  impossibility 
in  country  districts.  Philanthropy  has  made  this  possible,  also,  for  the  poor  of 
many  cities,  who  can  now  obtain  at  a  nominal  price,  at  various  distributing 
stations,  clean  fresh  milk  or  sterilized  milk  for  children.  The  results  in  ISTew 
York  from  the  stations  established  by  Mr.  ISTathan  Strauss  are  well  known. 
It  is  difficult  to  understand  the  conditions  of  milk  production  that  are  still 


PUBLIC    CONTROL    OF    MILK    SUPPLY.  45 

tolerated  in  rich  farming  communities,  in  towns,  and  in  villages,  since  experi- 
ence has  taught  how  quickly  a  good  quality  of  milk  can  be  secured  by  intelli- 
gent effort. 

In  every  locality  where  physicians  have  combined  to  secure  a  clean  pure 
milk  they  have  succeeded  promptly.  Eochester,  l^ew  York,  furnishes  an 
example  of  what  may  be  accomplished  by  a  capable  health  official,  and  the 
results  obtained  by  the  various  milk  commissions  organized  in  recent  years 
show  how  promptly  practical  results  follow  the  concerted  action  of  physicians. 
The  Milk  Commission  organized  by  the  Philadelphia  Pediatric  Society  and 
that  by  the  'New  York  County  Medical  Society  are  notable  examples.  Statis- 
tical information  is  already  forthcoming  showing  an  astonishing  decrease  in 
the  mortality  of  infants  directly  traceable  to  an  improvement  in  the  milk 
supply. 

What  has  been  accomplished  in  larger  and  smaller  cities  of  the  country  in 
the  production  of  certified  milk  by  milk  commissions  ought  to  be  matters  of 
common  knowledge  to  physicians  and  stimulate  them  to  similar  activities.  The 
first  Walker-Gordon  milk  was  supplied  from  an  ordinary  farm,  with  ordinary 
cows,  by  the  work  of  one  farmer's  family.  Some  encouraging  results  in 
Elmira,  InT.  Y.,  have  recently  been  reported,  wdiich  afford  a  good  illustra- 
tion of  what  may  be  done  in  smaller  places.  A  w^oman  was  found  with 
some  general  knowledge  of  the  benefit  of  clean  milk,  who  was  willino-  to 
take  up  the  work.  She  built  a  new  barn,  and  had  her  herd  tested  for  tuber- 
culosis. A  standard  of  10,000  bacterial  count  was  established  and  the  other 
usual  conditions  imposed.  The  milk  was  cooled,  bottled  within  a  few  min- 
utes after  it  was  drawn  and  then  put  into  a  crate,  the  top  of  which  was 
filled  with  crushed  ice.  The  night  and  morning  milk  was  delivered  to  the 
consumer  not  more  than  ten  hours  from  the  time  the  oldest  of  it  was  drawn 
the  night  before.  This  was  accomplished  simply  by  using  the  means  at  hand, 
and  what  has  been  done  in  Elmira  could  be  done  in  a  score  of  other  cities  of 
the  sam.e  size.  Continued  public  agitation,  aided  by  the  work  of  the  agricul- 
tural experiment  stations,  should  make  the  work  of  milk  production  a  trained 
industry  under  constant  public  supervision. 

Improvement  of  Housing  Conditions. — The  movement  for  im- 
proved housing  conditions  of  the  poor  in  cities  is  of  great  hygienic  sig-nificance. 
Overcrowding,  with  its  attendant  evils  of  bad  air,  uncleanliness, 
lack  of  sunlight,  and  bad  sanitation  is,  after  improper  and  insuf- 
ficient food,  the  greatest  cause  of  death  and  sickness  among  children. 
There  is  at  hand,  easy  of  access,  an  ample  bibliography  demonstrating  the 
wretched  conditions  existing  in  many  of  our  cities.  Booth  in  his  "  Life  and 
Labor  in  London "  says,  "  Crowding  is  the  main  cause  of  drink  and  vice." 
As  "  drink  and  vice  "  are  the  greatest  causes  of  hereditary  degenerations,  over- 
crowding, both  by  its  direct  and  indirect  influence  upon  the  health  of  children, 
must  be  reckoned  as  a  principal  source  of  physical  deterioration  among  them. 
Figure  33  shows  a  room  in  which  ten  persons  lived,  ate,  drank,  and  slept,  and 


46  HYGIENE    OF    INFANCY    AND    GIELHOOD. 

wliicJi  was  tlie  only  place  in  which  one  of  them,  a  boy  of  five  or  six,  could 
recover  from  a  broken  leg.  As  a  result  of  the  activity  of  social  workers  and 
philanthrojjists  it  has  been  demonstrated:  (1)  That  improvement  in  health 
promptly  follows  better  housing  conditions,  and  (2)  that  model  tenements  are 
a  paying  investment.    A  great  sanitary  reform,  therefore,  need  not  be  impeded 


Fig.  33. — The  Home  of  a  Family  of  Ten  Persons  in  Baltimore. 
(Taken  by  Mr.  Scott  of  Hughes  &  Co.,  Photographers,  Baltimore.) 

by  economic  reasons.  Stringent  tenement  house  laws  with  rigid  enforcement 
must  be  considered  a  vital  hygienic  necessity  for  the  health  of  a  large  number 
of  children. 

A  study  of  the  housing  conditions  in  Baltimore,  made  by  Miss  Janet  Kemp 
under  the  direction  of  the  Association  for  the  Improvement  of  the  Condition 
of  the  Poor  and  the  Charity  Organization  Society,  furnishes  a  recent  contribu- 
tion to  this  subject  (1907).  This  admirable  study  illustrates  well  the  necessity 
for  watchfulness  of  conditions  even  in  a  city  where  no  tenements  are  supposed 
to  exist,  and  shows  how  rapidly  the  growth  of  tenements  may  proceed  within 
the  four  walls  of  dwellings  intended  for  single  families.  With  our  present 
hygienic  knowledge,  the  sanitary  conditions  under  which  the  poor  live  in  over- 
crowded houses  and  tenements  should  not  be  tolerated  in  decent  communities 
(see  rig.  34).     The  hygienic  results  in  tenement  house  reform  aimed  at  by 


IMPEOVEMENT    OF    HOUSING    CONDITIONS. 


47 


such  movements  as  this  appeal  to  the  most  selfish  interests,  as  well  as  to  the 
most  altruistic.     The  children  of  Dives  in  his  palace  arc  menaced  by  the  con- 


FiG.  34. — A  Court  in  a  Crowded  City  District.     (From  "Housing  Conditions  in  Baltimore.") 

ditions   surrounding  Lazarus   in   the   slums.      Twenty-two   families    living   in 
forty-four  rooms  facing  each  other  across  a  small  court  with  no  other  outlook, 


48  HYGIElSrE    OF    IXFAWCT    AND    GIRLHOOD. 

sharing  among  them  two  privies  with  three  compartments,  and  one  hydrant, 
the  court  owned  privately  and,  therefore,  independent  of  the  Street  Cleaning- 
Department,  in  a  city  with  no  contagions  disease  hospital,  present  a  difficult 
problem  to  preventive  medicine  (see  Fig.  35). 


Fig.  35. — Toilet   Accommodations    for   Twenty-two    Families.     (From    "Housing   Conditions   in 

Baltimore.") 

An  interesting  question  might  be  raised  here  as  to  the  effect  on  the  health 
of  the  gTowing  child  of  life  in  the  apartment  houses  for  the  well-to-do,  which 
have  multiplied  with  such  rapidity  in  recent  years  in  all  large  centres  of 
population. 


PTTBLIC    PAEKS,    PUBLIC    PLAYGROUNDS,    PUBLIC    BATHS. 


49 


Public  Parks,  Public  Playgrounds,  Public  Baths. — The  exten- 
sion of  city  park  systems,  especially  the  establishment  of  small  parks, 
the  use  of  school  yards  and  city  lots  for  public  playgrounds, 
out-door  gymnasiums  and  swimming  pools  are  all  powerful  influences 
in  promoting  the  health  of  the  growing  girl.  Towns  as  well  as  cities  have 
much  to  gain  by  encouraging  out-door  life  among  children. 

Especial  emphasis  must  be  placed  on  the  necessity  of  making  adequate 
provisions  for  girls  in  all  arrangements  for  sports  and  games  in  the  open  air 


Fig.  36. — Open  Air  Gymnasium,   Girls'  Day.     Patterson  Park,  Baltimore. 


which  are  under  public  control.  Out-door  swimming  baths  and  gymnasiums 
for  boys  should  be  duplicated  for  girls,  or  reserved  for  them  at  specified  times 
(see  Fig.  36).  Traditions  as  to  what  is  proper  for  girls  are  difficult  to  over- 
come, but  mothers  must  learn  to  keep  their  little  daughters  in  the  open  air  as 
much  as  possible,  and  to  encourage  those  plays  and  sports  which  take  them 
put  of  doors.  The  public  playgrounds  where  girls  may  spend  hours  in 
the  open  air  under  watchful  control  are  a  great  educational  force  in  both  the 
physical  and  moral  development  of  the  child.  They  should  not  be  for  the 
poor  only,  but  also  for  those  who  can  afford  to  pay  for  the  care  given.  They 
ought  to  be  in  all  towns  and  villages,  where  it  should  be  possible  at  all  seasons 


50  hygiejste  of  infancy  and  girlhood. 

of  the  year  for  joimg  children  to  play  in  the  open  air  under  proper  guidance. 
It  would  be  difficult  to  estimate  the  beneficial  effect  of  such  out-door  life  luider 
efficient  direction  upon  the  health  of  girls. 

Public  aids  to  personal  cleanliness  by  the  establishment  of  public  baths 
and  laundries  in  congested  districts  of  large  cities  are  legitimate  charges 
upon  the  public  purse.  They  are  material  aids  to  encouraging  cleanliness  of 
children  among  those  classes  who  need  it  most. 

Protection  against  Infectious  Diseases. — Infectious  diseases  with 
their  sequelae  are,  after  malnutrition,  the  greatest  source  of  illness,  acute  and 
chronic,  among  children,  while  the  chronic  ill  health  of  adults  is  often  trace- 
able to  imperfect  recovery  from  some  of  the  ordinary  infectious  diseases  of 
childhood.  The  prevention  of  infectious  disease  is,  therefore,  of  the 
gTcatest  imjDortance  to  the  good  health  of  the  growing  girl.  Moreover,  there 
is  every  reason  to  believe  that  not  a  few  of  the  gynecological  affections  from 
which  so  many  women  suffer  have  their  starting  point  in  the  infectious  dis- 
eases most  common  in  childhood  (see  Chap.  X). 

The  knowledge  now  in  possession  of  scientific  medicine  as  to  the  etiology 
and  prophylaxis  of  many  infectious  diseases  is  ample  to  enormously  diminish 
their  incidence  in  child  life  and  their  effects  upon  the  health  of  the  adult.  It 
is  well  known  to  physicians  that  the  prevention  of  infectious  diseases  among 
children  involves:  (1)  Knowledge  of  the  exciting  cause,  or  of  some  effective 
method  of  preventive  inoculation;  (2)  power  to  control  those  external  con- 
ditions by  which  sjDCcific  infective  agents  are  multiplied  and  propagated; 
(3)  power  to  control  those  external  and  internal  factors  by  which  resistance 
to  infection  is  increased.  They  know,  too,  that  the  ability  of  the  individual 
phvsician  in  private  practice  to  limit  the  spread  of  infectious  diseases  is 
confined:   (1)   To  preventive  inoculations;    (2)  to  trying  to  secure  isolation; 

(3)  to  instructing  parents  in  matters  of  personal  and  public  hygiene;  (4)  to 
calling  to  his  assistance  such  administrative  control  as  is  operative  in  his  par- 
ticular community  for  the  enforcement  of  public  health  measures  for  the  com- 
mon good.  Sanitary  reforms  of  public  health  administration  are  as  necessary 
for  the  physician  in  his  practice  as  for  the  general  public. 

Among  the  measures  which  may  be  expected  to  materially  diminish  infec- 
tious diseases  in  the  future  are:  (1)  Multiplication  of  laboratories  for  research 
into  causes  of  infectious  diseases  and  the  measures  for  their  prevention;  (2) 
thorough  reorganization  of  public  health  departments  with  a  great  extension 
of  their  powers;  (3)  employment  of  such  health  officers  only  as  have  had 
special    training   for    their    work    or    have    shown    a    special    fitness    for    it; 

(4)  medical  inspection  of  all  school  children;  (5)  establishment  of  health 
laboratories,  at  such  convenient  centres  in  small  communities  that  all  physi- 
cians may  have  the  skilled  assistance  in  bacteriological  and  clinical  diagnosis 
which  the  best  municipal  laboratories  now  give  to  city  physicians;  (6)  estab- 
lishment of  isolation  hospitals  for  infectious  diseases,  or  isolation  wards  in  all 
hospitals  receiving  state  aid;  (7)  the  practice  of  better  personal  hygiene. 


HYGIENE    OF    THE    SCIIOOE    GIEI..  51 

Tlie  adoj)tion  of  effective  measures  of  public  hygiene  can  be  secured  only 
by  a  vigorous  campaign  of  education  in  the  principles  and  practice  of  pre- 
ventive medicine.  The  thinking  public  must  be  convinced  that  health  is  secured 
best  by  preventing  disease,  not  by  curing  it.  That  it  is  easier  to  obtain  from 
the  public  means  to  cure  than  to  prevent  is  illustrated  by  what  has  been  accom- 
plished in  the  campaigTi  against  tuberculosis.  State  aid  for  incipient  curable 
cases  is  -accepted  generally  as  good  public  policy,  w^hile  the  necessity  of  pro- 
vision for  the  isolation  of  advanced  cases,  which  are  the  greatest  menace  to 
public  health,  esj)ecially  to  that  of  children,  has  received  as  yet  little  public 
recognition. 

Summary. — 111  health  among  children  is  largely  the  result  of  post-natal 
influences.  To  maintain  their  life  and  promote  their  health  requires  suffi- 
cient and  proper  food,  fresh  air,  cleanliness,  sleep,  rest,  exer- 
cise, the  formation  of  hygienic  habits  by  education,  and  protection 
from  the  harmful  influences  of  environment.  Physicians  are  in- 
formed or  should  be  informed  about  these  matters,  but  their  knowledge  is  of 
little  value  unless  they  can  secure  its  practical  and  intelligent  application  in 
the  household  through  mothers  and  caretakers ;  and  in  public  through  public 
opinion,  legislative  enactment,  and  administrative  control.  The  duty  of  the 
profession,  so  far  as  hygiene  is  concerned,  is  to  inaugurate  some  systematic 
plan  for  instruction  of  mothers  of  all  classes  on  subjects  of  personal  hygiene ; 
and  of  the  general  j)"i^blic  in  matters  of  public  hygiene. 

HYGIENE    OF    THE    SCHOOL    GIRL. 

School-going"  Age. — Most  girls  spend  a  part  of  the  period  from  six  or  eight 
to  seventeen  or  eighteen  at  school.  Many  States  determine  this  fact  by  the 
enactment  of  compulsory  education  laws.  In  every  intelligent  community  the 
schools  are  tacitly  considered  to  offer  the  best  means  for  the  development  of 
the  mind  of  the  child ;  they  should  aid  and  supplement  the  home  in  the  develop- 
ment of  the  body.  lio  fixed  rule  can  be  given  as  to  the  age  at  which  the  small 
girl  should  be  placed  in  school ;  the  decision  in  each  case  must  be  based  upon 
a  comparative  study  of  both  the  home  and  the  school  and  the  physical  and 
mental  status  of  the  individual  child.  For  the  weak  and  anemic  girl  with 
poor  physical  inheritance  and  with  home  possibilities  of  good  nourishment  and 
out-door  life — six  to  eight  years  is  too  early;  the  same  girl  from  a  dirty 
insanitary  home  is  certainly  better  off  in  school. 

At  whatever  age  the  girl  enters  school,  her  education  has  already  been 
begun  and  carried  far  at  home ;  habits  have  been  formed,  principles  instilled, 
and  tendencies  developed  and  trained.  The  best  school  available  for  the  con- 
tinuation of  this  education  should  be  chosen,  co-educational  or  otherwise.  In 
early  school  life  at  least,  sex  difference  should  not  be  emphasized  in  the  selec- 
tion of  the  school  nor  in  courses  of  training.  There  is  no  essential  differ- 
ence in  the  physical  needs  of  growing  children.     All  animal  necessities  are  the 


52  HYGIENE    OF    INFANCY    AND    GIEXHOOD. 

same,  the  same  food  is  eaten,  cell  processes  arc  similar,  tlie  same  exercises  are 
enjoyed.  Boys  and  girls  like  equally  well  to  ride,  to  swim,  to  climb  trees,  to 
play  basket-ball.  Exercises  for  children  should  not  be  restricted,  or  adapted, 
or  classified  on  a  sex  basis  as  boyish  and  girlish.  Playfair  says,  "  Up  to  the 
time  of  puberty  there  is  comparatively  little  difference  between  the  sexes  in 
health,  in  disease,  or  in  any  other  condition.  Conventionally,  they  are  separated 
and  different  modes  of  education  and  training  wall  soon  make  such  difference 
as  there  is  more  marked,  but  boys  and  girls  play  together,  w^ork  together,  and 
are  generally  on  a  footing  of  perfect  equality,  there  being  little  essential  which 
distinguishes  one  sex-  from  the  other."  As  education  progresses  the  boy  is 
trained  to  courage,  endurance,  and  manliness,  is  taught  to  protect  the  weak,  to 
be  depended  upon,  to  provide  for  himself  and  others,  and,  in  short,  is  educated 
with  the  idea  that  he  is  to  be  the  head  of  a  family,  to  bear  civic  responsibility, 
to  assist  in  guiding  national  affairs,  to  be  economically  independent.  The 
girl  is  trained  to  directly  opposite  notions;  she  is  expected  to  be  helpless  and 
dependent,  and  this  undoubtedly  is  a  distinct  hygienic  disadvantage. 

In  recent  years  there  has  been  a  recoil  from  older  ideas  and  the  trained 
intelligence  of  educated  women  has  been  successfully  applied  to  many  of  the 
problems  of  the  child's  education.  As  the  education  of  mothers  progresses  and 
becomes  more  specific,  still  better  results  in  the  education  of  girls  will  be 
attained.  ISTo  degree  of  native  intelligence,  no  advantage  of  modern  educa- 
tional method  is  too  great  for  the  woman  who  is  to  be  a  mother,  no  knowledge, 
but  may  be  put  to  use  in  the  care  of  a  home  or  training  of  a  child.  There  is 
no  possibility  of  over  development  of  the  powers  of  either  father  or  mother 
when  we  consider  that,  biologically  speaking,  the  production  and  education  of 
children  is  the  greatest  human  achievement. 

It  is  the  duty  of  parents  to  bear  children  with  good  physical  and  mental 
capacities  and  to  train  their  natural  endowments  to  their  most  perfect  develop- 
ment. Each  successive  generation  should  be  superior  to  the  preceding  by  at 
least  some  small  increment  of  physical  strength  and  mental  or  moral  vigor. 
Oppenheim  says,  "  The  spirit  of  the  hour  calls  for  a  strenuous  effort,  a  desire 
to  improve  upon  the  past,  a  noble  dissatisfaction  that  can  be  quieted  only  by 
an  active  exhibition  of  individual  endeavor."  The  nearest  duty  to  the  indi- 
vidual is  but  the  greater  duty  to  the  race,  and  a  parent's  apparently  egoistic 
effort  for  the  welfare  of  his  own  offspring  is,  in  a  larger  sense,  a  contribution 
to  race'  development. 

Hygienic  Habits  of  the  School  Girl. — A  girl  at  the  school  age  is  the  product 
of  her  home  environment  and  brings  to  the  new  conditions  of  her  life  a  phys- 
ical preparation  which  is  the  direct  result  of  her  inheritance  and  home  care. 
Her  general  condition  and  power  of  resistance  should  be  at  the  maximum. 
She  should  have  certain  fixed  hygienic  habits.  Her  food,  her  clothing,  her 
hours  of  rest  and  of  sleep  should  be  regulated  by  the  solicitous  care  of  intelli- 
gent parents.  The  breakfast,  the  bath,  the  care  of  the  nails  and  teeth,  attention 
to  the  evacuation  of  the  bowels  should  be  matters  of  daily  routine.     These  early 


HYGIENE    OF    THE    SCHOOL    GIKL.  53 

lessons  in  physical  education  are  an  important  part  of  the  parents'  responsi- 
bility to  the  child. 

A  surprising  number  of  school  children  habitually  eat  no  breakfast.  In- 
ability to  take  breakfast  is  always  sufficient  reason  for  keeping  a  child  from 
school.  Two  reasons  for  this  are  obvious :  the  work  of  the  morning  will  make 
far  greater  demand  upon  the  child's  vitality,  if  energy  furnished  by  break- 
fast is  lacking ;  and,  in  the  interest  of  the  school,  the  fact  should  be  determined 
whether  the  child  is  suffering  the  initial  symptoms  of  contagious  disease,  in 
which  case  she  should  not  be  permitted  to  mingle  with  other  children. 

A  daily  bath  may  be  considered  a  hygienic  necessity.  It  is  a  matter 
of  common  observation  that  mothers  who  are  careful  to  bathe  a  baby  daily 
throughout  infancy  consider  a  weekly  bath  adequate  for  the  same  child  as  it 
grows  older.  This  is  true,  not  in  the  homes  of  the  poor  alone,  but  often  in 
those  where  complete  bathing  facilities  exist  and  the  physical  work  of  keeping 
clean  is  reduced  to  a  minimum.  Under  the  conditions  existing  at  present  in 
many  homes  the  schools  must  furnish  instruction  in  personal  hygiene,  and  it 
would  be  an  advantage  if  they  were  equipped  with  shower  baths  in  order  to 
carry  out  such  teaching  practically.  In  some  continental  cities  the  shower 
bath  is  part  of  the  daily  school  routine.  Teachers  should  encourage  children 
from  homes  lacking  bathing  facilities  to  make  use  of  the  public  baths  in  those 
cities  where  such  systems  exist.  The  child  should  have  learned,  too,  that  clean 
clothing  is  as  necessary  to  personal  cleanliness  as  a  clean  skin  and  that  the 
underclothing  should  be  frequently  changed.  Many  children  from  the  better 
classes  are  not  carefully  trained  in  this  particular. 

The  care  of  the  teeth  in  young  children  is  of  great  importance.  Too 
much  stress  can  hardly  be  laid  upon  the  necessity  of  early  training  in  habits 
of  mouth  cleanliness,  not  only  because  of  the  importance  of  preserving  the 
teeth,  but  also  because  of  the  relation  of  the  bacterial  flora  of  the  mouth  to 
many  infectious  processes. 

The  habit  of  daily  evacuation  of  the  bowels  is  largely  a  matter 
of  early  training.  'No  more  important  habit  can  be  cultivated  in  infancy  and 
childhood.  Most  cases  of  persistent  constipation  in  adult  life  are  attributable 
to  a  failure  to  establish  this  early  habit,  to  dietetic  errors,  or  to  neglect  of  a 
tendency  towards  constipation  (see  Chap.  VIII).  Haste  and  disorder  in  the 
early  morning  hours  are  very  unfavorable  to  the  establishment  of  regular 
habits  of  going  to  stool.  The  hour  of  rising  should  be  regulated  to  allow 
time  sufficient  for  the  bath,  the  toilet,  the  breakfast,  and  the  evacuation  of 
the  bowels.  Breakfast  should  be  ready  promptly  at  the  hour ;  many  cases  of 
ill  health  in  growing  children  can  be  traced  to  a  habit  of  going  to  school 
without  breakfast,  or  of  swallowing  their  food  hastily  without  mastication,  or 
to  a  failure  to  observe  the  regular  time  of  going  to  stool. 

The  Dress  of  Young  Girls. — The  method  of  dressing  little  girls 
according  to  present  standards  is  almost  ideal.  Simplicity  of  style,  lack  of 
constriction  and  pressure,  lightness  combined  with  warmth,  support  by  shoul- 


54  HYGIENE    OF    INFANCY   AND    GIRLHOOD. 

ders  and  thorax,  materials  well  chosen,  and  shoes  of  good  shape  combine  to 
make  the  well  dressed  yonng  girl  a  strong  contrast  to  her  older  sisters. 

Physical  Condition  of  the  School  Girl. — It  is  very  desirable  that  the  physical 
condition  of  every  girl  abont  to  enter  school  be  determined  by  medical  exami- 
nation. Unless  a  child  is  in  good  physical  condition,  she  may  not  only  be 
unable  to  profit  by  the  advantages  offered,  but  even  be  harmed  by  attendance 
at  school.  It  is  futile  to  attempt  to  educate  children  Avho  are  not  in  physical 
or  mental  condition  to  be  educated ;  moreover,  the  school-going  age  is  the  most 
favorable  period  for  attention  to  many  defects  or  tendencies  which  have  been 
overlooked  during  infancy  and  early  childhood.  Corrective  and  preventive 
work  may  be  carried  far  during  these  plastic  years,  and  much  may  be  accom- 
plished toward  right  development  which,  later  in  life,  would  be  found  to  be 
impossible.  It  is  equally  important  that  the  child  entering  school  should  not 
be  a  source  of  danger  to  other  children,  as  she  will  be  if  she  is  suffering  from 
any  form  of .  communicable  disease. 

Unless  both  the  physical  and  mental  status  of  each  child  is  intelligently 
determined,  she  cannot  be  properly  classified.  Underfed  children,  those  who 
have  errors  of  vision,  adenoids,  or  scoliosis  are  frequently  considered  to  be 
mentally  retarded,  whereas  experience  has  shown  that  many  such  cases  may 
be  returned  to  the  normal  classes,  if  their  physical  condition  receives  the 
necessary  attention.  Of  a  large  number  of  Boston  school  children  classed  as 
truant  or  backward  ninety-five  per  cent  were  found  to  be  physically  defective. 
Under  the  conditions  of  the  present  day  a  system  of  medical  inspection 
of  schools  furnishes  the  most  efficient  method  for  obtaining  the  facts 
which  will  enable  any  community  to  render  the  schools  the  best  means  for  the 
development  of  the  child  and  for  its  preparation  to  receive  the  greatest  benefit 
from  education.  It  is  astonishing  that  the  public  has  been  so  slow  to  recog- 
nize the  value  of  what  seems  such  a  self  evident  proposition.  Many  European 
countries  have  had  a  system  of  partial  inspection  for  some  years.  Japan 
introduced  medical  inspection  in  1893  and  in  1906  had  eight  thousand  four 
hundred  and  twenty-four  inspectors,  while  the  whole  United  States  had  but  six 
hundred.  Although  medical  inspection  in  the  United  States  has  been  slow 
of  adoption  and  is  limited  in  application,  ISTew  York  has  the  most  compre- 
hensive and  highly  developed  system  of  medical  inspection  of  schools  in  the 
world.  It  was  established  in  1896,  one  hundred  and  fifty  inspectors  were 
appointed,  and  during  the  first  year  six  thousand  eight  hundred  and  twenty- 
nine  pupils  were  excluded  on  account  of  various  diseases.  In  1902  six  oculists 
were  added  to  the  staff.  Subsequently  a  corps  of  trained  nurses  made  the 
work  more  effective  by  securing  immediate  attention  to  minor  ailments  and 
to  skin  and  parasitic  troubles.  A  short  statement  of  results  during  the  year 
between  March  27,  1905,  and  March  31,  1906,  is  instructive. 


.-''  PHYSICAL    CONDITION    OF    THE    SCHOOL    GIKL.  55 

Number  of  Examinations  made,  79,065. 

Poor  nntritioii 4,537 

Enlarged  ant.  cervical  glands , 22,493 

Enlarged  post,  cervical  glands 4,989 

Chorea   1,184 

Cardiac  disease 1,332 

Pulmonary  disease   885 

Skin  disease 1,574 

Deformity  of  spine 674 

Deformity  of  chest 500 

Deformity  of  extremities 663 

Defective  vision 24,534 

Defective  hearing 1,633 

Defective  nasal  breathing 8,974 

Defective  teeth 29,386 

Defective  palate   936 

Hypertrophied  tonsils 13,411 

Post-nasal  growths   7,375 

Defective  mentality 1,477 

l^umber  v^here  treatment  was  necessary 50,913 

That  sixty-three  per  cent  of  all  children  who  enter  the  schools  of  'New 
York  need  medical  treatment  is  a  tremendous  indictment  against  the  efficiency 
of  the  home,  and  demonstrates  also  the  inability  of  the  medical  profession  to 
prevent  disease  when  its  relation  to  the  family  is  entirely  dependent  upon  the 
volition  of  parents.  There  are  no  available  published  statistics  for  comparison 
from  private  schools  which  draw  their  pupils  exclusively  from  the  well-to-do 
classes,  but  even  here,  wherever  careful  medical  examinations  and  re-examina- 
tions have  been  made,  a  surprisingly  large  percentage  of  girls  have  been  found 
suffering  from  remediable  physical  defects,  the  most  common  of  which  are 
poor  nutrition,  defects  in  vision,  defective  hearing,  enlarged 
tonsils  and  post-nasal  growths,  and  chronic  skin  affections.  To 
these  various  causes  of  ill  health  a  careful  analysis  may  trace  most  of  the 
disturbances  of  function  of  the  reproductive  organs  in  girls  and  young  women 
which  do  not  result  from  congenital  malformations,  the  effects  of  trauma,  or 
infections.  The  educational  processes  of  the  schools  are  not  entirely  blame- 
less, but  they  are  not  responsible  for  the  large  percentage  of  acquired  ill 
health  in  women  so  often  charged  against  them. 

Faulty  nutrition  is  the  source  of  more  ill  health  among  school  girls 
than  all  other  causes  combined.  Measurements  of  large  numbers  of  school 
children  have  shown  clearly  the  direct  relation  existing  between  nutrition  and 
growth.  Chlorosis,  many  skin  troubles,  low  power  of  resistance 
to  some   acute  and  chronic  infections,   slow  recovery   after   acute 


56  HYGIENE    OF    INFANCY   AND    GIELHOOD. 

infections  diseases,  and  a  low  average  of  general  health  are  all 
directly  traceable  to  malnutrition.  A  relatively  small  number  of  under- 
fed children  reach  a  reasonable  proficiency  in  their  school  work.  Good 
nutrition,  therefore,  is  essential  to  good  education.  This  ques- 
tion of  nutrition  is  one  for  the  family,  but  its  recog-nized  importance  has 
found  expression  in  some  localities  in  Continental  Europe  in  the  provision  of 
breakfasts  and  luncheons  for  the  poor,  with  the  result  of  astonishing  better- 
ment in  both  physical  and  mental  condition  of  the  children.  But  evidences 
of  malnutrition  are  common,  also,  among  girls  of  the  better  classes,  who  often 
fail  to  eat  enough  plain,  nourishing  food,  or  suffer  from  loss  of  appetite  con- 
sequent upon  an  indulgence  in  unsuitable  food  at  the  family  table,  or  upon 
sweets  obtained  between  meals  from  candy  and  cake  shops  and  soda-water 
fountains  in  the  vicinity  of  school  houses.  A  warm,  nourishing,  mid- 
day luncheon  is  essential  for  a  girl's  good  health.  School  sessions 
must  be  arranged  with  this  in  view,  and  where  the  distance  makes  it  impos- 
sible for  the  girl  to  go  home  to  obtain  it,  the  school  should  see  that  suitable 
provision  is  made  in  or  near  the  school  building.  In  this  latter  case  the  food 
furnished  should  be  supervised  by  the  school  principal,  and  an  effort  be  made, 
at  least,  to  guide  the  choice  of  the  individual  girl  as  to  the  kind  and  quantity 
of  food  eaten,  Thomas  Madden  Moore  says :  "  If  the  State,  for  reasons  of 
public  policy,  determines  that  all  children  shall  be  compulsorily  educated  from 
their  earliest  years,  it  should  certainly  afford  the  means  by  which  this  may  be 
least  injuriously  and  most  effectively  carried  out,  by  providing  sufficient  food 
as  well  as  education  for  every  pauper  child  compelled  to  attend  school." 

Condition  of  Eyes  of  School  Girls. — The  result  of  the  examination  of  the 
eyes  of  school  children  in  those  schools  where  medical  inspection  has  been 
introduced  are  sufficiently  significant  to  warrant  the  statement  that  no  child 
should  be  permitted  to  enter  school  without  having  had  the  eyes  examined  by 
an  ophthalmologist.  The  ophthalmic  inspectors  of  I^ew  York  City  found 
thirty-three  and  one-third  per  cent  of  children  in  the  schools  with  defects  of 
vision  of  sufficient  importance  to  interfere  with  the  proper  pursuit  of  their 
studies.  The  effect  of  eye-strain  on  the  general  health  of  the  child,  the  possi- 
bility of  some  interdependence  between  eye-strain  and  certain  disorders  of 
menstruation,  insomnia,  and  nervousness,  the  presence  of  eye-strain  as  a 
causative  factor  in  the  production  of  scoliosis  are  all  subjects  which  are  being 
earnestly  discussed,  and  the  conclusions  of  those  who  can  speak  with  authority 
show  that  no  defects  of  vision  can  be  regarded  as  trivial.  Many  parents  are 
extremely  averse  to  sending  their  children,  especially  girls,  to  an  ophthalmol- 
ogist, permitting  the  child  to  suffer  the  consequences  of  a  physical  defect  with 
no  more  reasonable  excuse  than  the  dislike  of  the  esthetic  effects  of  glasses. 
Attention  to  the  eyes  of  children  on  entering  school  would  protect  them  against 
the  increasing  percentage  of  defects  of  vision  in  the  higher  schools.  Dr.  Kerr, 
from  his  observations  in  London,  found  that  ninety-five  per  cent  of  children 
between  six  and  six  and  one-half  years  of  age  have  normal  visual  acuity,     A 


PHYSICAL    CONDITIO]Sr    OF    THE    SCHOOL    GIEL.  57 

steady  increase  in  myopia  is  noted  in  the  ascending  grades.  Dr.  Hermann 
Colin,  after  testing  ten  thousand  pupils,  found  twenty-two  per  cent  with 
myopia  in  the  youngest  classes  and  fifty-eight  per  cent  in  the  higher.  School 
construction  and  school  appliances  should  recognize  the  needs  of  the  eyesight 
of  the  school  child  in  the  lighting  and  color  of  rooms,  size,  form  and  type  of 
hooks,  work  from  black-boards,  school  seating,  methods  of  teaching  writing, 
substitution  of  paper  for  slates.  Kindergartens  require  too  much  close  work 
from  children. 

Condition  of  Ears,  Nose,  and  Throat. — Many  girls  in  both  public  and  private 
schools  are  found  to  have  defective  hearing  in  one  or  both  ears.  Since  ninety 
per  cent  of  such  cases  are  probably  curable,  if  discovered  early  and  properly 
treated,  it  becomes  a  matter  of  great  importance  that  the  cases  which  have 
escaped  detection  until  the  school-going  age  should  receive  suitable  care  before 
a  condition  of  permanent  deafness  is  established.  Many  cases  of  defective 
physical  development  and  impaired  health  are  directly  due  to  the  limitation 
of  breathing  capacity  resulting  from  hypertrophied  tonsils  and  post-nasal 
growths.  Inasmuch  as  the  tonsils  and  the  peri-tonsillar  mucous  membrane  of 
the  j)harynx  are  often*  the  portals  of  infection  for  acute  rheumatism,  endo- 
carditis, and  otitis  media  with  mastoiditis,  abnormal  conditions  of  the  tonsils 
and  naso-pharynx,  both  acute  and  chronic,  must  receive  careful  and  prompt 
attention.  Acute  tonsillitis  in  children  can  never  be  looked  upon  as  an  unim- 
portant disease,  and  following  such  attacks  children  should  be  kept  from  school 
until  their  health  is  fully  restored.  Kisch  holds  that  there  is  some  interde- 
pendence, either  nervous  or  circulatory,  between  hypertrophy  of  the  tonsils 
and  disorders  of  menstruation,  and  cites  instances  of  retardation  of  the  appear- 
ance of  menstruation  and  lack  of  development  at  puberty  which  were  quickly 
corrected  after  the  removal  of  hypertrophied  tonsils.  This  observation  receives 
some  confirmation  in  the  fact  that  a  large  proportion  of  the  cases  of  either 
slight  or  severe  dysmenorrhea  among  one  hundred  school  girls  between  the 
ag-es  of  thirteen  and  eighteen,  under  careful  medical  supervision,  had  enlarged 
tonsils,  or  had  had  them  removed.  The  rapid  development,  both  mental  and 
physical,  frequently  observed  in  the  individual  girl  after  surgical  attention  to 
these  conditions  is  most  striking,  l^o  less  marked  is  the  improvement  after 
operation  in  minor  conditions,  as  the  adenoid  expression,  mouth  breathing, 
defective  nasal  development,  and  the  hoarse  or  nasal  voice  frequently  accom- 
panying enlarged  faucial  and  pharyngeal  tonsils.  Without  doubt  future  inves- 
tigation will  show  causative  relations  between  adenoids  and  serious  diseases 
not  at  present  referred  to  them,  but  we  have  even  now  sufficient  knowledge 
to  insist  that  the  development  of  the  growing  girl  shall  not  be  threatened  by 
the  lack  of  their  removal. 

The  importance  of  determining  the  exact  physical  status  of  each  girl  upon 
entering  school  has  been  emphasized.  It  is  equally  essential  that  the  results 
of  such  examination  be  followed  by  skilled  attention  to  the  defects  discovered. 
It  is  of  small  avail  to  the  welfare  of  the  individual  girl  that  the  fact  has  been 


58  HYGIENE    OF    INFANCY    AND    GIRLHOOD. 

revealed  that  the  eyes  are  myopic,  that  scoliosis  is  present,  or  that  adenoids 
obstruct  the  nasal  passages,  if  means  are  not  taken  to  remove  such  handicaps. 
Unfortunately,  parents,  and  even  family  physicians,  frequently  oppose  any 
active  measures  for  removing  such  defects,  as  in  a  case  of  advanced  scoliosis, 
recognized  by  the  school  physician  in  its  incipiency,  which  failed  to  have  any 
effective  treatment  because  of  the  attitude  of  the  family  physician. 

School  Buildings  and  Appliances  and  the  Health  of  the  School  G-irl. — If  the 
girl  presents  herself  at  the  school  clean  and  well,  she  should  find  the  environ- 
ment of  the  school  favorable  to  the  preservation  of  her  health  and  furnishing 
protection  against  infectious  diseases.  It  may  be  truthfully  said  that  most 
American  schools  do  not,  at  present,  afford  such  environment.  Ideal  condi- 
tions can  be  secured  only  by  efficient  sanitary  oversight  of  school  construction, 
school  furnishings,  and  school  administration.  When  one  considers  that  the 
schools  are  often  centres  of  infections,  possibly  the  most  common  source  for 
young  people,  it  is  evident  that  all  communities  should  establish  medical  inspec- 
tion and  sanitary  supervision  as  a  measure  of  public  hygiene.  Indeed  it  is 
questionable  whether  compulsory  school  attendance  is  warrantable  without  the 
protection  afforded  by  such  compulsory  supervision.  School  architecture  has 
made  great  strides  in  recent  years,  and  many  modern  school  buildings  in  both 
city  and  country  districts  are  admirably  adapted  to  their  purpose;  but  even 
in  these,  the  hygienic  demands  of  the  school  have  not  always  received  the 
attention  demanded  by  their  importance,  while  many  old  school  buildings  are 
entirely  unsuitable  for  use,  on  account  of  their  location,  construction,  lack  of 
suitable  heating  and  ventilation,  and  of  proper  lighting.  In  all  school  build- 
ings, even  the  best,  school  management  is  responsible  for  important  hygienic 
necessities  that  often  receive  scant  attention ;  over-crowding  and  improper  seat- 
ing are  common,  out-houses  and  toilet  rooms  are  insufficient,  unsuitable,  or 
uncared  for;  methods  of  school  cleaning  are  inefficient  and  even  dangerous; 
drinking  cups  are  used  in  common;  school  books,  pencils,  and  other  appliances 
used  in  common  are  not  cleaned  nor  disinfected ;  children  habitually  dirty  are 
not  separated  from  the  clean,  nor  is  there  provision  anywhere  for  school  baths. 
A  more  widespread  knowledge  of  existing  conditions  in  schools,  as  well  as  a 
better  general  knowledge  of  sanitation,  will  be  necessary  before  better  sanitary 
conditions  will  be  common  in  all  schools. 

The  number  of  cases  of  communicable  parasitic  and  skin  diseases  discov- 
ered among  school  children  by  medical  examiners  suggests  the  desirability  of 
separating  the  habitually  dirty  children  from  the  clean.  The  services  of  the 
school  nurse  in  following  up  cases  of  this  nature  have  been  productive  of  very 
marked  improvement  in  the  condition  of  personal  cleanliness  of  individual 
children.  Health  talks  to  mothers  under  the  joint  supervision  of  educational 
and  health  authorities  Avould  be  far-reaching  in  hygienic  results. 

The  dangers  of  dust  as  a  carrier  of  disease  germs  make  a  reform  in 
methods  of  cleaning  school-rooms  necessary.  Janitors  and  care-takers  must  be 
supervised  and  trained  in  the  best  methods  of  moist  cleaning  and  dusting. 


PHYSICAL,    TRAINING    OF    THE    SCHOOL    GIKL    AND    MEDICAL    GYMNASTICS. 


59 


Boston  is  said  recently  to  have  spent  one  thousand  dollars  in  one  year  for 
feather-dusters ! 

Out-houses  and  toilet-rooms  must  receive  more  enlightened  attention. 
Dirty,  unsanitary,  and  unsuitable  closets  are  common,  and  usually  there  is 
no  supervision  except  that  given  by  the  care-taker.  The  conditions  of  these 
closets  is  in  many  ways  a  menace  to  health  as  well  as  to  morals.  Moreover 
many  cases  of  constipation  in  adult  life  may  be  traced  back  to  school  condi- 
tions where  the  closets  provided  were  so  disgusting  as  to  inhibit  in  a  sensitive 
child  the  desire  to  go  to  stool,  or  to  evacuate  the  bladder. 

All  teachers  of  the  young  should  be  instructed  in  the  elements  of  personal 
and  of  school  hygiene.  Their  intelligent  initiative  and  cooperation  is  neces- 
sary in  all  measures  for  rendering  school  attendance  a  healthful  experience. 
The  teacher's  ideas  of  ventilation,  for  instance,  are  what  eventually  determine 
the  condition  of  the  air  of  the  school-room ;  her  example  in  matters  of  per- 
sonal cleanliness,  neatness,  and  clothing  may 
influence  markedly  the  habits  of  the  girls 
under  her  care.  ISTo  system  of  medical  super- 
vision can  be  adequate  or  effective  without  the 
cordial  cooperation  of  teachers  who  have  an 
intelligent  knowledge  of  the  objects  to  be 
gained. 

Physical  Training  and  Medical  Gymnastics. 
— Carefully  supervised  physical  training  is 
one  of  the  most  important  and  rational  fac- 
tors in  the  life  of  the  school  girl.  J.  Madison 
Taylor  says :  "  Children  cannot  be  expected  to 
grow  up  properly  unless  directed."  This  fact 
is  easily  demonstrated  by  a  comparative  study 
of  girls  who  have  had  every  favorable  oppor- 
tunity for  spontaneous  growth  and  those  who 
have  had  the  advantages  of  systematic  train- 
ing in  a  modern  gymnasium.  Indeed  the 
physical  differences  between  girls  of  sixteen 
or  seventeen  who  have  had  well-directed  gym- 
nasium work  and  those  who  have  not  had  it 
are  so  marked  that  an  experienced  examiner 
has  little  difficulty  in  separating  the  one  class 
from  the  other  by  simple  inspection.  ]^o  one 
with  medical  training  who  has  had  the  oppor- 
tunity of  examining  large  ninubers  of  healthy 
girls  in  preparatory  schools  and  observing  the 
effects  of  good  gymnasium  work  upon  them, 

can  fail  to  become  an  enthusiastic  advocate  of  systematic  educational  gym- 
nastics as  a  necessary  part  of  a  girl's  education. 


Fig.  37. 


Moujiij  Gymnasium  Suit, 
USED  IN  Madame  Osteeberg's 
Physical  Training  College, 
England. 


60 


HYGIENE    OF    INFANCY    AND    GIRLHOOD. 


Various  systems  of  gymnastic  training  are  used  in  this  country  and  each 
system  has  certain  advantages,  but  whatever  the  system,  the  work,  to  be  use- 
ful, must  be  regular,  systematic,  and  adapted  to  the  needs  of  the  average 
healthy  girl.  It  should  he  given  by  a  special  teacher  trained  for  the  work, 
should  require  a  special  dress  for  the  girls  (see  Fig.  37),  and  should  have  a 
room  built  and  equipped  for  the  purpose.  It  needs  always  careful  and  con- 
tinued medical  supervision.  It  must  seek  to  gain  two  results:  (1)  The  gen- 
eral systemic  effects  of  exercise,  such  as  improvement  in  respiration,  circula- 
tion, digestion,  etc.,  including  the  acquisition  of  increased  nervous  control  over 
bodily  movements;  (2)  the  correction  of  physical  defects,  such  as  faults  of 
posture,  carriage,  etc.,  which  are  not  the  result  of  pathological  changes  in  tis- 
sues, but  are  largely  due  to  the  environment  of  school  life. 

All  the  systemic  effects  of  exercise  gained  in  the  gymnasium  could  doubt- 
less be  obtained  from  out-door  athletics  with  the  additional  advantages  of 
the  open  air,  were   it  possible  to  make  girls  take  this  in   definite   amounts 

systematically  and  regularly 
under  guidance,  but  this  is 
not  possible.  The  corrective 
work  distinguishes  the  re- 
sults gained  in  the  gym- 
nasium. The  necessity  for 
such  work  is  shown  by  the 
fact  that  eighty  per  cent  of 
girls  who  enter  college  with- 
out previous  good  gymna- 
sium training  show  defects 
of  posture  and  carriage 
which  are  almost  entirely 
lacking  in  those  who  have 
had  systematic  gymnastic 
work.  In  this  connection 
reference  should  be  made  to 
the  subject  of  proper  school 
seating,  as  this  is  one  im- 
portant factor  in  causing 
defects  that  need  remedy. 
Although  the  principles  of 
correct    school    seating    are 

Fig.  38. — Adjustable  Desk  with  Narrow  Box;    Both  Seat       ^ray,^      aiiTi-nla        -fpTo-      cplinol^ 
AND  Desk  are  Adjusted  to  the  Pupil  when  Seated.  very      Simple,      lew      scuuoib 

have  proper  seats  and  desks. 
Many  are  non-adjustable,  and  many  of  the  so-called  adjustable  seats  and  desks 
cannot  be  properly  fitted  to  the  individual  pupil.  The  rules  to  be  followed  are : 
(1)  The  height  of  the  seat  should  equal  the  distance  from  the  floor  to  the 
under  part  of  the  knee;  (2)  the  height  of  the  desk  should  equal  the  distance 


■■ 

V 

^Hp 

^^  '^^I^^^I^IB 

■ 

^^^^^^^^f  ^ 

.-.r. 

M 

Ks 

P 

m 

■^■p 

^fk 

'----r-^    ^ 

m 

w        M 

■ 

r^- 

^^3 

^ 

PHYSICAL    TEAINIISTG    OF    THE    SCHOOL    GIKL    AND    MEDICAL    GYMNASTICS. 


61 


from  floor  to  elbow  plus  tliree-quarters  of  an  inch ;  ( 3 )  there  should  be  a  minus 
distance  of  at  least  half  an  inch  between  front  edges  of  desk  and  seat ;  (4)  the 
box  of  the  desk  should  be  sufficiently  narrow  at  its  front  edge  to  permit  above 
adjustment  without  pressure 
upon  knees.  Measurements 
should  be  taken  and  the  desk 
and  seat  of  each  girl  prop- 
erly adjusted  at  the  begin- 
ning of  each  school  year. 
The  growth  of  the  girl 
should  be  watched  during 
the  year  and  readjustment 
made  whenever  necessary. 
The  accompanying  illustra- 
tions show  an  ideal  adjust- 
able desk  (Fig.  38)  prop- 
erly fitted,  also  a  so-called 
adjustable  desk  incapable  of 
adjustment  on  account  of 
the  depth  of  the  box  at  the 
front  edge  (Fig.  39). 

In  every  scheme  of  phys- 
ical training  out-door  ath- 
letics should  supplement  the 
work  in  the  gymnasium. 
The  habit  of  out-door  exer- 
cise should  be  established  in  the  early  years  of  life  and  the  growing  girl  taught 
to  regard  it  as  one  of  the  essentials  of  healthful  living. 

Several  hours  each  day  should  be  spent  in  the  open  air  by  every  girl 
attending  school.  It  would  be  well  if  the  school  could  make  compulsory  a 
definite  amount  of  out-door  exercise  under  guidance.  Nearly  all  the  sports 
and  games  boys  are  taught  in  the  open  air  can  be  used  equally  well  for  girls, 
when  guarded  by  medical  inspection.  Playf air  says :  "  One  chief  reason  for 
the  more  frequent  break-down  of  girls  than  boys  at  school  is  probably  that  the 
male's  work  is  safeguarded  by  an  amount  of  physical  exertion  in  the  way  of 
sports  which  tends  to  keep  him  in  health,  and  that  this  is  usually  compulsory 
in  boys'  schools,  and  optional  in  girls'."  School  grounds  should  be  ample. 
Athletic  fields  for  girls  are  as  necessary  as  for  boys.  Playgrounds  in  parks 
should  be  set  aside  for  girls.  They  should  receive  instruction  in  swimming. 
School  swimming  pools  and  public  swimming  baths  (see  Fig.  40)  afford  facili- 
ties for  such  instruction,  which  are  easily  popularized.  The  habit  of  taking 
exercise  in  the  open  air,  firmly  fixed  on  the  girl,  makes  it  a  necessity  for  her 
when  her  formal  education  is  completed,  and  this  is  of  inestimable  valiie  in 
maintaining  and  promoting  her  health  in  after  life. 


1m. 


-Desk  "with  Irons  Similar  to  that  Sitoavn  in  Fig. 
This  is  sold  as  an  adjustable  desk,  but  the  box  is  six 
inches  in  width  at  the  front  and  cannot  be  adjusted  to  the 
majority  of  pupils  without  pressure  upon  the  knees. 


38 


62 


HYGIENE    OF    IlSTFAlSrCT    AND    GIET.HOOD, 


The  medical  pxaminer  must  carefully  differentiate  in  school  girls  those 
cases  of  slight  myopathic  asymmetry;  faults  of  carriage,  as  protruding  head 
and  abdomen;  and  careless  postnre,  from  those  more  serious  cases  in  which  a 
slight  lateral  deviation  of  the  spine  has  been  neglected  nntil  it  has  become 
l^athologic,  involving  the  bony  structures  and  requiring  special  corrective  work, 


Fig. 


40. — Swimming  Pool  Belonging  to  Public  Bath  System.     Patterson  Park,  Baltimore, 

Girls'  day. 


or  medical  gymnastics.  The  prevention  of  scoliosis,  and  its  early  cure, 
is  of  especial  importance  for  girls,  because  of  the  changes  which  may  result  in 
the  bony  pelvis  and  their  effects  upon  the  mechanics  of  parturition.  The  early 
recognition  of  this  defect  in  girls  is  imperative.  Most  cases  are  unfortunately 
not  subjected  to  physical  examination  until  well  established.  Every  general 
practitioner  should  know  the  diagnosis  and  the  probable  etiology  of  scoliosis, 
but  the  treatment  should  not  be  undertaken  by  the  school  gymnasium.  Schul- 
thess  thinks  that,  although  schools  and  attitudes  in  study  may  be  a  detrimental 
factor  in  lateral  curvature,  they  do  not  furnish  the  chief  etiological  influence. 
J.  M.  Taylor  holds  that  many  faults  of  attitude  are  due  to  original  errors  of 
construction,  some  hereditary.  One  of  the  latest  theories  of  the  etiology  of 
scoliosis  assumes  the  faulty  construction  of  the  bodies  of  the  vertebrae  as  the 
predisposing    factor.      This    theory   receives    some    confirmation    in    the    fact 


PHYSICAL    TRAlNllSfG    OF   THE    SCHOOL   GIKL    AND    MEDICAL    GYMNASTICS. 


63 


demonstrated  by  tlie  medical  examination  of  many  school  cliildren  from  six 
to  eight  years  of  age  that  very  few  are  absolutely  symmetrical  even  at  this 
early  age.  All  sucli  children  need  careful  watching  throughout  the  whole 
period  of  school  life,  in  order  to  determine  whether  they  improve  constantly 
under  general  care,  careful  attention  to  nutrition,  and  simple  bi-lateral  work 
in  the  gjmmasium,  or  whether  there  is  increasing  asymmetry  and  a  necessity 
for  corrective  work.  Tlie  treatment  of  scoliosis  is  not  a  legitimate  part  of 
school  work,  and  should  not  be  undertaken  by  the  school  gymnasium.  It 
needs  medically  supervised  special  individual  work,  given  by  women  specially 
trained  in  the  apjDlication  of  gymnastics  and  massage  to  orthopedic  cases,  as 
well  as  sufficiently  intelligent  and  sympathetic  to  encourage  the  child  and 
inspire  her  to  put  forth  her  best  exertion  in  the  persistent  and  long-continued 
effort  needed  for  the  improvement  of  her  deformity.  The  child  should  not  be 
taken  from  school  unless  it  is  clearly  shown  that  the  school,  even  when  the 
amount  of  work  it  demands  is  modified,  is  undoubtedly  affecting  her  general 
health.  Much  harm  often  comes  to  the  girl  by  separating  her  from  her 
class,  interfering  with  her  education,  and  concentrating  her  attention  upon 
her  physical  condition,  thus  sowing  the  seeds  of  physical  introspection  and 
invalidism. 


Fig.    41.- 


-Faulty   Carriage   in   Young   Girl 
WITHOUT  Actual  Defect. 


Fig.  42.  —  Effect  of  Physical  Training  upon 
Faulty  Carriage  Shown  in  Fig.  41. 


64 


nYGIEXE    OF    IXFAIv'CY    AXD    GIEEITOOD. 


Eeference  to  the  illustrations  (see  Figs,  -il  aud  4il )  Avill  show  the  possi- 
bility of  improTcmcnt  iu  carriage  under  supervised  exercise.      The  results  of 


Fig.    43. — A   Case   of  Slight  Lateral   Cueva-       Fig.    44. — Same   Case   as  that   Shotvx  in  Fig. 

TURE    OF   SpIXE    IX   A   ScHOOL   GlEL    DETECTED  43    AFTER    OXE    MoXTH'S    SYSTEMATIC    EXER- 

BY  School  Physical  Ex.^iixatiox.  cise. 

treatment  in  a  case  of  slight  lateral  curvature  in  a  school  girl  Tvhose   defect 
was  discovered  by  medical  examination  in  school  and  given  special  treatment 


Fig.  45. — A  Case  of  Se-st:re  Lateral  Cuhva-   Fig.  46. — S.^me  Case  as  that  Showx  ix  Fig  45 

TUKE   OF   the    SpLVE    IX    A    SCHOOL    GlEL.  AFTER   ThREE   MoXTHS'   D.A.ILY   EXERCISE. 


SCirOOL    LIFE    IN"    ITS    RELATION    TO    PUBERTY, 


65 


of  the  kind  suggested,  is  shown  in  Figures  43  and  44.     Similar  improvement 
in  a  severe  case  is  shown  in  Figures  45  and  46. 

School  Life  in  Its  Relation  to  Puberty. — It  is  useless  to  concentrate  atten- 
tion u]30u  one  period  of  a  girl's  life  and  to  attempt  by  over  solicitude  at  this 
time  to  remedy  the  effects  of  early  mistakes  in  hygienic  living  and  hered- 
itary tendencies.  It  is  unreasonable  to  anticipate  normal  puberty  in  the  weak, 
poorly  nourished,  and  imperfectly  developed  girl  who  has  been  permitted  to 
violate  the  laws  of  health  throughout  childhood.  The  advantage  of  a  good 
physical  start  in  life  is  most  apparent  at  the  age  of  sexual  development.  The 
physiologic  demands  upon  the  growing  girl  are  greatest  at  this  time.  That 
the  period  from  twelve  and  a  half  to  fourteen  and  a  half  years  in  girls  is 
that  of  gTeatest  increase  in  height  and  weight  is  indicated  by  the  following 
tables : 


TABLE   SHOWING  RATE   OF   INCREASE   IN  WEIGHT   OF   GIRLS   FROM  AGE  OF 

62  to  151  years.     Frederic  Burk,  Am.  Jour.  Psych.,  April,  1898 
Several  Thousand  Observations. 


Age. 

Average  for  each  age. 

Absolute  annual  increase. 

Annual  increase. 

In  pounds. 

In  pounds. 

Per  cent. 

6i 

43.4 

n 

47.4 

4.3 

9.9 

8i 

52.5 

4.8 

10.0 

9i 

57.4 

4.9 

9.3 

m 

62.9 

5.5 

9.6 

m 

69.5 

6.6 

10.5 

m 

78.7 

9.2 

13.3 

m 

88.7 

10.0 

12.7 

14i 

98.3 

9.6 

11.9 

15| 

106.7 

8.4 

8.5 

TABLE  SHOWING  RATE  OF  GROWTH  IN  HEIGHT  OF  GIRLS  FROM 

6i  to  15i  years.     Rep.   U.  S.  Com.  of  Ed.,  1896-97.     Franz  Boas. 

Number  op  Observations  4,000. 


Age. 

Average  height  for 

Absolute  annual 

Percentage  annual 

each  year. 

increase. 

increase. 

6i 

Inches. 
43.3 

Inches. 

7i 

45.7 

2.4 

5.5 

8i 

47.7 

2.0 

4.4 

9* 

49.7 

2.0 

4.2 

lOi 

51.7 

2.0 

4.0 

m 

53.8 

2.1 

4.1 

m 

56.1 

2.3 

4.3 

m 

58.5 

2.4 

4.3 

144 

60.4 

1.9 

3.2 

15i 

61.6 

1.2 

2.0 

66  HYGIElSrE    OF    INFANCY    AND    GIRLHOOD. 

That  strength  docs  not  keep  pace  with  muscle  growth  is  shown  by  the  falling 
off  in  strength  tests,  and  is  plainly  indicated  by  the  careless  carriage  and 
awkwardness  of  many  girls  at  this  age.  Inability  to  give  fixed  attention  to 
work  and  listlessness,  demonstrate  accompanying  mental  inertia.  The  school 
curricnlnm  should  take  cognizance  of  the  physiological  and  psychical  changes 
going  on  in  the  pubescent  girl.  Under  twelve  years  the  pressure  and  stimu- 
lation of  the  school  are  of  little  consequence  to  the  normal  girl.  She  is  not 
likely  to  respond  mentally  in  a  way  harmful  to  her  health,  but  in  tlie  follow- 
ing years  the  demands  of  the  present  school  Mall  contain  factors  unfavorable 
to  her  best  development.  Henderson  in  his  "  Education  and  the  Larger  Life  " 
has  expressed  the  conditions  well  when  he  says :  "  The  lower  schools  would  be 
good  if  the  high  schools  would  let  them,  and  the  high  schools  would  be  good 
if  the  colleges  would  let  them,  and  the  colleges  would  teach  the  knowledge  of 
most  worth,  if  the  community  would  let  them.  Apparently,  it  is  a  superior 
madness  which  drives  us."  Whatever  harm  educational  methods  of  this  high 
pressure  system  inflict  upon  a  girl's  health,  close  observation  of  girls  in  college 
and  in  preparatory  schools  certainly  places  the  responsibility  upon  the  pre- 
paratory schools.  School  work  must  be  adapted  to  the  capacity  of  the  average 
girl,  not  to  the  ability  of  the  exceptionally  gifted. 

The  school,  however,  is  frequently  held  responsible  for  the  ill  health  of 
individual  girls,  when  it  has  really  furnished  the  only  favorable  environmental 
conditions  under  which  they  have  lived,  B.  Sachs  finds  the  chief  causes  of 
break-down  in  school  life  are  the  tendencies  of  parents  to  force  a  child  to 
keep  up  with  other  children  who  are  mentally  or  physically  stronger  and  in 
the  conditions  of  life  in  homes  and  in  society.  "  Mental  fatigue,"  he  says, 
''  is  no  more  a  morbid  symptom  than  physical  fatigue,  provided  it  be  tran- 
sitory and  be  recovered  from  promptly  after  a  short  period  of  relaxation.  It 
is  the  school  alone  which  in  our  American  life  exerts  the  slight  restraining 
influence  which  our  children  need  above  all  else." 

To  what  extent  the  injurious  consequences  which  may  reasonably  be 
ascribed  to  school  conditions  manifest  themselves  by  disturbances  •  of  menstrua- 
tion is  a  difficult  question  to  answer.  Certainly  the  amount  of  menstrual  dis- 
turbance occurring  among  school  girls  has  been  much  over-estimated.  Engel- 
mann  has  tabulated  five  thousand  cases  of  beginning  menstruation  and  finds 
about  sixty  per  cent  with  more  or  less  menstrual  pain.  Chapman  thinks  that 
fully  seventy-five  per  cent  of  girls  Avould  give  a  history  of  painful  menstrua- 
tion. Clark  says,  "  The  menstrual  function  should,  of  course,  occur  painlessly 
and  with  perfect  periodicity,  but  it  is  quite  rare  to  find  this  function  unat- 
tended with  some  discomfort  and  very  frequently  there  is  the  most  intense 
cramplike  pain,  which  totally  incapacitates  the  patient  for  one  or  more  days 
before  the  onset  of  the  fiow  and  for  one  or  two  days  after  it  is  established." 
These  figures  are  not  corroborated  by  a  study  of  the  menstrual  history  of  a 
group  of  school  girls  under  medical  supervision  for  several  years  preceding 
and  following  puberty.     Such  a  study  shows  that  in  about  seventy-five  per  cent 


HYGIENE    OP    PUBERTY.  67 

of  school  girls  normal  menstruation  occurs.  In  a  representative  group  from 
a  private  school  only  twenty-five  per  cent  reported  habitual  discomfort.  Fifty- 
six  per  cent  of  these,  or  fourteen  per  cent  of  the  whole,  remained  away  from 
school  regularly  one  or  two  days ;  thirty -six  per  cent  of  these,  or  nine  per  cent 
of  the  whole,  had  sufficient  pain  to  go  to  bed  for  one  or  two  days.  Statistics 
of  girls  of  the  same  grade  in  public  schools,  the  girls  being  less  likely  to  report 
slight  discomfort,  show  still  smaller  percentages. 

Summary.- — The  best  physical  development  of  the  growing  girl  demands : 
(1)  More  rational  home  care  and  training  throughout  childhood 
and  youth ;  (2)  school  conditions  which  furnish  every  facility 
for  healthful  life  and  growth,  best  secured  by  a  wide  extension  of  an 
effective  system  of  medical  inspection  and  sanitary  supervision;  (3)  com- 
pulsory physical  training  in  the  schools  ;  (4)  revision  of  the 
curriculum  of  preparatory  schools  to  relieve  the  pressure  of 
school  work. 


HYGIENE    OF    PUBERTY    AND    HYGIENE    OF    OCCUPATION. 

Hygiene  of  Puberty.- — Reference  has  already  been  made  to  the  necessity  of 
recognizing  the  years  marking  the  advent  of  puberty  in  school  curricula.  It 
is  convenient  to  take  up  here  more  directly  a  consideration  of  the  personal 
hygiene  of  this  period.  A  rational  hygiene  of  puberty  must  be  based  upon  an 
understanding  of  the  physiological  and  psychical  changes  which  the  girl  is 
undergoing.  It  is  a  period  for  wise  direction  and  sympathetic  guidance.  All 
the  resources  of  physical  and  moral  education  must  be  brought  into  play  to 
establish  right  habits  of  living,  for  the  future  woman  is  moulded  at  this  time. 
The  physiology  of  fatigue  is  too  obscure  at  present  to  determine  with  scien- 
tific exactness  the  amount  of  work,  mental  or  physical,  which  may  be  taken 
as  a  safe  standard  for  the  normal  girl  with  average  mental  capacity,  but  it  is 
certain  that  from  her  twelfth  to  her  fifteenth  year  she  should  have  the  benefit 
of  any  doubt,  and  the  school  and  home  should  require  too  little  rather  than 
too  much.  Strain  and  stress  of  emotional  life,  in  especial,  must  be  avoided. 
Much  of  the  re-education  needed  as  a  therapeutic  measure  in  the  treatment 
of  the  psychasthenia  of  adult  women  will  become  unnecessary  when  the  girl  is 
properly  educated  at  this  age  in  the  home  and  in  the  school. 

ITutrition. — This  is  a  point  which  requires  close  attention.  Diseases  of 
malnutrition  common  at  this  period  depend  as  often  upon  improper  food 
as  upon  insufficient  food.  Rich  and  poor  may  suffer  equally;  the  one 
from  overfeeding  and  improper  feeding,  the  other  from  lack  of  food.  A 
plain,  mixed  diet  taken  at  regular  intervals  must  be  insisted  upon.  Patience 
and  perseverance  on  the  part  of  mothers,  with  cordial  cooperation  between 
mothers  and  teachers,  will  be  required  in  this  matter  of  diet.  Girls  frequently 
suffer  from  the  dietetic  errors,  dietetic  fads,  and  dietetic  neglect  of  the  family 
table.     It  is  as  easy  to  teach  them  to  eat  good  plain  food  at  regular  intervals 


68  -    HYGIENE    OP    INFANCY   AND    GIRLHOOD. 

as  it  is  to  teach  them  to  read  good  books.  The  school  hours  of  the  child  and 
the  business  hours  of  the  father  may  conflict,  but  the  home  must  meet  the 
difficulties. 

The  importance  of  a  knowledge  of  dietetics  in  relation  to  health  and  gTowth 
cannot  be  urged  too  strongly  upon  the  general  practitioner.  Mothers  and 
young  girls  need  very  definite  instructions  as  to  the  kind  of  food  to  be  taken 
and  its  quantity. 

It  must  not  be  forgotten  that  the  processes  of  nutrition  involve  the 
excretion  of  waste  as  well  as  the  in-take  of  new  material.  The  care  of 
the  health  of  the  growing  girl  involves  the  prevention  and  often  the  cure  of 
constipation  as  well  as  attention  to  the  demands  for  evacuation  of  the  bladder. 

Exercise. — Exercise  in  the  open  air,  after '  nutrition,  is  the  greatest 
hygienic  need  of  puberty.  The  necessity  and  use  of  systematic  gymnastic 
work  under  medical  supervision  as  an  essential  part  of  the  school  education 
has  already  been  insisted  upon,  but  this  work  in  the  gymnasium  cannot  take 
the  place  of  exercise  in  the  open  air.  The  school  and  the  home  should  pro- 
vide for  out-door  sj)orts  and  games.  Tennis,  golf,  hockey,  basket-ball,  rowing, 
swimming  and  skating  are  all  particiilarly  useful  for  the  developing  girl.  All 
sports  into  which  the  spirit  of  competition  enters  should  be  carefully  guarded. 
The  value  of  inter-school  and  inter-collegiate  athletics  for  girls  is  extremely 
doubtful,  as  excessive  physical  and  mental  strain  cannot  be  avoided.  The 
athletic  ideal  is  not  to  be  aimed  at;  what  is  required  is  to  cultivate  a  desire 
for  the  pleasurable  satisfaction  that  comes  with  healthy  fatigue  of  the  muscles 
by  work  in  the  open  air.  Among  all  exercises  great  stress  should  be  laid  upon 
walking;  girls  should  acquire  a  love  for  brisk  cross-country  walking.  Care 
in  advising  exercise  and  athletics  must  be  observed ;  neurotic  girls,  girls  with 
heart  lesions,  anemia  and  other  physical  disabilities  must  be  kept  off  basket- 
ball teams,  tennis  tournaments,  and  other  games  where  excitement  runs  high. 
Physical  trainers  cannot  be  trusted  to  judge  of  medical  conditions,  and  family 
physicians  are  frequently  at  fault.  This  matter  of  exercise  in  the  open  air 
should  receive  careful  attention  from  the  family  physician;  offhand  advice 
to  refrain  from  some  particular  exercise,  or  advice  to  strenuous  exercise  not 
adapted  to  the  individual  girl  often  work  irreparable  harm.  The  general 
practitioner  should  be  familiar  with  the  physiology  of  exercise,  with  the 
methods  of  physical  training  used  in  the  schools,  with  the  nature  of  the  vari- 
ous athletic  games  and  their  adaptation  to  the  needs  of  the  individual  girl. 
He  should  be  able  to  give  definite  directions  as  to  the  kind  of  exercise  to  be 
taken  and  its  amount.  It  is  his  duty  before  prescribing  exercise  for  any  par- 
ticular girl  to  make  a  thorough  physical  examination,  and  before  advising 
against  exercise  to  examine  most  carefully  into  the  life  and  habits  of  the  girl 
for  causes  for  her  complaints  rather  than  to  ascribe  them  to  systematic 
exercise. 

Rest  and  Sleep. — Eight  or  nine  hours  should  be  the  minimum  require- 
ment for  sleep,   and  this  should  be  taken  in  a  w^ell  ventilated,  clean  room. 


HYGIENE    OF    PUBERTY.  69 

Alcoves,  recesses,  dark  rooms,  corners,  are  unsuitable  places  for  beds.  Girls 
quickly  acquire  the  habit  of  sleeping  with  all  the  outside  air  they  can  get, 
irrespective  of  its  temperature,  and  the  windows  of  the  bed-room  should  be 
freely  opened  at  all  seasons  of  the  year.  The  bed  clothing  must  be  sufficient 
for  warmth,  but  light  in  weight.  Single  beds  should  be  provided.  Simplicity 
in  the  furnishings  of  the  bed-room  and  scrupulous  cleanliness  are  to  be  aimed 
at.  Bare  floors  with  rugs  easily  cleaned,  washable  curtains  and  hangings,  and 
walls  easily  renovated  are  desirable.  With  a  better  understanding  of  the  rela- 
tion of  dust  to  disease  we  may  look  for  great  modifications  in  the  popular 
standard  for  the  furnishing  of  bed-rooms,  in  which  approximately  one-third 
of  life  is  spent. 

Employment  at  Home. — The  time  available  for  exercise  in  the  open 
air  is  interfered  with  by  many  unnecessary  exactions  upon  the  girl  in  the 
household.  What  these  are  would  involve  a  discussion  of  the  whole  question 
of  the  organization  of  the  household  and  the  teaching  of  domestic  science 
which  has  no  place  here.  Household  work  should  form  an  essential  part  of 
the  education  of  every  girl ;  but  the  unnecessary  and  thoughtless  demands 
made  upon  the  growing  girl  in  poorly  organized  households  are  part  of  a  bad 
moral  and  physical  training. 

Long  hours  of  practice  on  the  piano  must  be  avoided.  The 
posture,  if  long-continued  is  bad,  the  confinement  is  bad,  and  the  attempt  at 
prolonged  attention  is  bad.  If  skill  in  the  use  of  musical  instruments  can  be 
acquired  only  by  long  consecutive  sittings,  then,  for  the  average  girl,  a  choice 
must  be  deliberately  made  between  music  lessons  and  good  health.  A  reform 
in  the  method  of  teaching  music,  especially  the  piano,  is  much  needed. 

Sewing  on  the  machine  for  long  consecutive  periods  is  objec- 
tionable for  precisely  the  same  reasons.  Long-continued  stand- 
ing for  any  purpose  is  also  harmful.  Frequent  changes  of  posture  give  most 
favorable  conditions  for  a  normal  pelvic  circulation. 

Bathing. — The  bathing  habit,  if  not  already  established,  must  receive 
attention.  The  bath  for  cleanliness  and  the  bath  for  stimulation  should  be 
enforced.  Most  girls  must  be  taught  that  the  minimum  of  cleanliness  requires 
a  full  bath  at  least  twice  a  week  with  soap  and  warm  water,  and  at  the  least, 
daily  attention  to  the  exposed  parts  of  the  body,  to  the  axillae,  the  external 
genitalia,  and  to  the  feet.  It  is  curious  to  note  hov/  averse  mothers  are  to  the 
use  of  soap  in  care  of  the  face  of  the  girl  for  fear  of  its  effects  upon  the  skin, 
when  they  cheerfully  acquiesce  in  its  necessity  for  the  delicate  skin  of  the 
baby.  It  is  difficult  even  in  acne  to  enforce  proper  cleanliness  of  the  skin  of 
the  face. 

Most  girls,  too,  must  be  taught  the  value  of  a  cold  bath  as  a  part  of  the 
morning  toilet,  in  the  form  of  a  plunge,  a  sponge,  or  a  shower,  with  brisk 
friction  subsequently.  Such  a  bath  should  follow  any  form  of  active  exercise. 
Baths  other  than  these  referred  to  belong  to  the  resources  of  hydrotherapy 
and  ought  to  be  taken  under  medical  supervision. 


70 


HTGIENE    OF    INFANCY    AND    GIELHOOD. 


Clothing. — At  the  establishment  of  puberty  with  the  develoj)ment  of  the 
physical  characteristics  of  the  woman,  the  child's  clothes  are  replaced  by  those 
of  the  adult.  A  woman's  clothes  are  the  despair  of  the  hygienist.  The  dic- 
tates of  fashion  pay  slight  attention  to  the  physiological  demands  of  clotliing. 
Tight  collars,  tight  corsets,  heavy  skirts  supported  by  the  hips  and  waist, 
shoes  too  small  and  badly  shaped,  and  a  total  disregard  of  the  use  of  clothing 
in  the  maintenance  of  body  temperature  characterize  the  dress  of  the  so-called 
"  well-dressed  "  woman.  With  such  standards  before  her,  with  the  awakened 
desire  of  making  herself  attractive  forcing  itself  upon  her  consciousness,  the 
difficulties  of  adajDting  the  dress  of  the  pubescent  girl  to  her  hygienic  needs 
are  well-nigh  insurmountable. 

Rebellion  at  first  against  the  corset  is  strong,  but  she  accepts  it,  adapts  her 
feelings  to  it,  and  finally  defends  it.  In  a  thousand  measurements  of  women 
and  girls,  showing  a  constriction  of  the  waist  varying  from  one  to  five  inches 


Fig.  47. — Interior  Applarance  of  a  Cadaver  Showixg  Constriction  and  Displacement  Due  to 
Corsets.     (From  forth-coming  "Sm-gery  of  the  Kidnej',"  by  H.  A.  Kelly.) 

and  more,  one  single  woman  in  the  series  could  be  brought  to  acknowledge 
that  her  corset  felt  too  tight.  While  opinions  as  to  the  causal  relation  between 
the  corset  and  pelvic  congestions,  movable  kidney  and  enteroptosis  in  women 
differ,  there  is  no  doubt,  as  Glenard  has  shown,  that  the  corset  produces  arti- 
ficially, while  it  is  worn,  the  dislocations  of  the  organs  brought  about  by  other 
causes.  This  is  well  illustrated  by  reference  to  the  diagrams  (see  Fig.  47). 
As  an  article  of  dress  for  the  girl  the  corset  must  be  looked  upon  as  distinctly 
prejudicial  to  healtli,  and  as  entirely  unnecessary.  Other  more  hygienic  gar- 
ments may  be  made  to  give  whatever  support  the  bust  needs. 


HYGIENE    OF    PUBEKTY. 


71 


The  weight  of  clothing  and  its  support  should  be  regulated.  The  weight 
of  skirts  should  he  kept  at  a  minimum.  It  is  a  rule  to  which  few  exceptions 
are  found  that  the  entire  weight  of  women's  skirts 
is  supported  from  the  waist — and  yet  the  reasons 
for  supporting  a  woman's  clothes  hj  the  thorax  are 
greater  than  those  demanding  such  support  for  the 
little  girl.  The  clothing  sold  in  the  shops  represents 
the  habits  of  the  community,  and  the  impossibility 
of  buying  suitable  garments  for  girls  of  sixteen 
shows  how  early  the  women's  clothes  with  their  dis- 
advantages are  forced  upon  the  girl. 

A  properly  fitting  shoe  is  necessary  for  the  sup- 
port of  the  body,  for  correct  carriage,  and  for  the 
maintenance   of   the   integrity   of   the    arch   of   the 

foot.     The  shoe  of  the  average  young  woman  is  too  small,  while  its  shape  is 

grotesque  and  absurd  (see  Fig.  48).  Its  size,  its 
shape  and  its  heel  interfere  to  such  an  extent  with 
the  mechanics  of  support  and  with  the  circulation 


Fig.  48. — Shoemaker's  Walk- 
ing Shoe  for  Girls. 


Fig.  49. — Impression  of  Foot 
OF  School  Girl  with  Out- 
line OF  Shoe  Worn. 


Fig.  50. — (a)  Proper  Soles  for  Normal  Feet.    (6)  Shoemaker's 
Soles  (Whitman).      (From  W.  L.  Pyle,   "Personal  Hygiene.") 


as  to  make  it  both  a  direct  and  indirect  cause  of  local  injury  and  of  remote 
disturbances  of  the  general   health.      ISTo  reform   in  woman's   dress   is   more 


72  HTGIEXE    OF    IIS'FAiSrCT    AXD    GIRLHOOD. 

urgently  needed  than  an  adaptation  of  the  shoe  to  the  function  of  the  foot. 
Figure  49  shows  the  relation  between  a  foot  of  normal  shape  and  the  shoe  into 
which  it  is  commonly  forced.  Figure  50  shows  shoes  adapted  to  the  shape 
of  the  foot  and  the  proper  fulfilment  of  its  function  as  a  means  .of  support 
to  the  body. 

Instruction  of  Growing  Girl  in  the  Physiology  of  Reproduc- 
tion.— All  women  who  have  the  care  of  growing  girls  in  the  school  or  in  the 
home  should  have  an  iutelligent  knowledge  of  the  physiological  changes  going 
on  in  the  developing  girl.  They  should  have  the  ability  to  teach  girls  in  some 
proper  way  before  the  first  menstrual  period  a  few  simple  facts  about  repro- 
duction, and  the  very  little  that  is  known  about  the  significance  of  the  men- 
strual flow.  Such  instruction  will  be  of  benefit  to  girls  morally  as  well  as 
physically.  There  is  little  doubt  that  the  ignorance  which  envelops  this  whole 
subject  for  the  average  mother  and  teacher,  and  the  secrecy  maintained  about 
it,  result  in  great  harm  to  the  mind  and  body  of  the  developing  girl.  Sexual 
information  girls  get  in  plenty,  but  the  sources  from  which  it  is  obtained  are 
too  often  ignorant  and  vicious  servants  and  companions,  obscene  literature,  and 
bad  advertisements.  There  is  no  real  difiiculty  in  giving  the  necessary  instruc- 
tion in  a  helpful  way,  provided  it  is  given  with  knowledge  and  sympathy  by 
a  woman  who  has  the  affection  and  confidence  of  the  girl.  This  is  a  part  of 
the  education  of  the  girl  that  preeminently  belongs  to  the  mother,  but,  unfor- 
tunately, for  the  present  at  least,  this  teaching  must  be  relegated  in  most  cases 
to  the  schools,  and  therefore  teachers  should  be  properly  instructed.  The 
general  introduction  of  the  study  of  biology  into  high  school  courses  and  into 
those  of  teachers'  training  schools  is  making  women  teachers  familiar  with  the 
great  facts  of  organic  reproduction,  and  th'e  difficulties  of  giving  them  ade- 
quate instruction  in  the  physiology  and  hygiene  of  the  reproductive  system 
have  practically  disappeared.  The  nature  study  now  common  in  most  schools 
will  make  the  task  of  instructing  girls  of  thirteen  comparatively  easy,  provided 
the  teacher  has  tact  and  knowledge. 

Great  care  must  be  taken  not  to  direct  the  attention  of  the  girl  to  her 
sexual  organs,  nor  to  sexual  things.  It  is  for  this  reason  that  an  active  life 
out  of  doors  with  many  varied  interests  outside  of  herself  should  be  encour- 
aged. Her  reading  must  be  carefully  guided.  Introspective  habits  should  be 
discouraged,  and  an  objective  life  cultivated. 

Hygiene  of  Menstruation. — The  periods  of  the  menstrual  flow  in  the 
healthy  girl  require  no  marked  deviation  from  her  normal  hygienic  habits. 
Great  cleanliness  of  person  and  of  clothing  must  be  enjoined,  in  opposition  to 
the  prevalent  idea  that  bathing  and  changing  underclothing  must  be  avoided. 
The  daily  bath  must  not  be  intermitted ;  a  cold  sponge  bath  may  be  substituted 
for  a  cold  plunge,  but  there  is  no  necessity  for  changing  the  habit  of  daily 
bathing,  while  the  underclothing  requires  more  frequent  changing  than  at 
other  times.  Girls  should  not  be  taught  to  use  a  vaginal  douche  after  each 
menstrual  period. 


HYGIENE    OF    PUBERTY.  73 

The  diet  should  be  plain  and  unstinmlating,  in  other  words  a  diet  suitable 
for  a  girl  at  any  time  may  be  taken  during  the  menstrual  period.  There  are 
many  fanciful  ideas  about  the  effect  of  various  articles  of  food  upon  the  men- 
strual flow,  but  there  is  no  evidence  that,  in  the  normal  girl,  the  function  is 
affected  by  using  any  particular  article  of  diet. 

Excessive  exercise  should  be  avoided.  Many  women  take  habitually  the 
same  amount  of  exercise,  and  teachers  of  physical  training,  who  do  not  suffer 
from  dysmenorrhea,  make  no  difference  with  their  systematic  exercise,  appar- 
ently with  no  ill  effects.  Some  healthy  girls  habitually  rest  a  day  or  two  at 
the  menstrual  period  because  they  have  been  taught  to  do  so,  but  unless  there 
is  marked  dysmenorrhea,  this  is  not  necessary — on  this  question  of  rest  during 
the  menstrual  period  nothing  has  been  added  to  our  knowledge  to  vitiate  the 
conclusion  drawn  by  Dr.  Mary  Putnam  Jacobi  in  1875  ("  The  Question  of 
Rest  for  Women  during  Menstruation  " ) .  She  says,  "  There  is  .nothing  in 
the  nature  of  menstruation  to  imply  the  necessity  or  even  the  desirability  of 
rest  for  women  whose  nutrition  is  really  normal.  The  habit  of  periodical 
rest  in  them  might  easily  become  injurious.  Many  cases  of  pelvic  congestion 
developed  in  healthy,  but  indolent  and  luxurious,  women  are  often  due  to  no 
other  cause." 

The  treatment  of  the  disturbances  of  the  menstrual  function  will  be  dis- 
cussed in  future  chapters,  but  it  may  be  permitted  here,  in  discussing  the 
hygiene  of  the  growing  girl,  to  emphasize  the  necessity  of  extreme  care  to  avoid 
the  suggestion  of  pelvic  disease  to  the  young  woman  or  to  the  growing  girl.  Un- 
fortunately, the  possibility  of  giving  or  withholding  the  suggestion  is  not  often 
in  the  power  of  the  physician.  The  teaching  of  gynecology  twenty-five  years 
ago,  with  the  constant  pelvic  examinations,  local  treatment  with  douches,  tam- 
pons, etc.,  dilatations  and  curettage  for  "  the  moral  effect  "  has  fixed  pretty 
firmly  in  the  minds  of  women  the  idea  that  the  most  frequent  source  of  ill 
health  of  girls  is  to  be  found  in  the  pelvis.  A  prominent  gynecologist  of  a  gen- 
eration ago  told  his  patients  that  if  a  woman  knew  the  danger  she  was  in  from 
her  pelvic  organs  she  would  not  step  from  her  carriage  to  the  pavement;  the 
effect  of  such  teaching  upon  practitioners  and  patients  has  been  harmful  in  the 
extreme.  It  has  been  hardly  possible  in  the  present  generation  for  a  neurotic  or 
hysterical  girl,  or  one  suffering  from  malnutrition,  to  reach  the  age  of  seventeen 
without  having  passed  through  some  more  or  less  prolonged  gynecological  treat- 
ment by  the  general  practitioner,  or,  if  she  has  avoided  the  physician,  without 
having  used  largely  the  various  nostrums  or  local  applications  of  the  patent 
medicine  venders.  It  is  difficult  even  for  a  healthy  girl  to  rid  her  mind  of 
constant  impending  evil  from  the  uterus  and  ovaries,  so  prevalent  is  the  idea 
that  woman's  ills  are  mainly  "  reflexes  "  from  the  pelvic  organs.  If  symp- 
toms are  suggestive  of  pelvic  disturbance  a  young  woman  should  be  examined 
under  an  anaesthetic.  Local  treatment  should  be  avoided  unless  absolutely 
necessar3^  On  the  other  hand,  pelvic  examination  when  symptoms  point  to  its 
necessity,  must  not  be  postponed  by  considerations  of  false  delicacy.     Here 


74  HYGIENE    OF    INFANCY    AND    GIRLHOOD. 

again  women  suffer  from  the  secrecy  wliicb^  for  them,  has  surrounded  all  the 
phenomena  of  reproduction. 

Hygiene  of  Occupation. — The  relation  of  the  school  to  the  health  of  the  girl 
during  the  school-going  period  (eight  to  seventeen)  has  been  fully  considered, 
hut  as  there  is  an  increasing  tendency  to  prolong  the  education  of  girls  beyond 
the  high  school,  and  since  many  girls  leave  school  before  the  age  of  seventeen, 
a  discussion  of  the  hygiene  of  the  growing  girl  would  be  incomplete  without  a 
reference  to  the  conditions  favorable  or  unfavorable  to  her  health  in  the  envi- 
ronment in  which  she  finds  herself  subsequent  to  her  withdrawal  from  the  sec- 
ondary school.  This  involves  a  discussion  of  the  relation  to  the  health  of  girls 
and  young  women,  (1)  of  industrial  life,  (2)  of  the  social  life  of  the  leisure 
classes,  (3)  of  college  life.  This  part  of  the  subject  may  be  conveniently  re- 
ferred to  as  the  hygiene  of  occupation,  using  the  phrase  with  another 
than  its  usual  hygienic  significance. 

Occupation  both  mental  and  physical  is  a  physiological  necessity  for  girls 
and  women ;  some  regular  and  systematic  work,  whether  in  the  household  or 
outside  of  it,  contributes  to  their  health,  while  the  lack  of  it  is  one  of  the  most 
frequent  sources  of  ill  health  among  unmarried  women.  It  must  be  remem- 
bered that  occupation  should  be  interesting  and  should  not  require  excessive 
physical  or  mental  strain.  More  women  probably  suffer  in  health  from  lack 
of  work  than  from  its  effects.  Occupation  is  harmful  to  health,  if  the  external 
conditions  under  which  work  is  done  are  unhygienic,  or  if  by  its  nature  it 
requires  too  great  an  expenditure  of  energy  or  too  prolonged  attention.  Women 
too  often  hold  occupation  responsible  for  bad  effects  upon  the  health  w^hich  are 
really  due  to  the  faulty  personal  hygiene  of  the  worker. 

Influence  of  Industrial  Life  upon  the  Health  of  Women. — The 
agitation  of  the  question  of  child  labor  in  the  last  few  years  has  revealed  con- 
ditions for  young  girls  some  of  which  are  inhuman  and  intolerable — they  are 
so  bad  as  to  be  absolutely  defenceless  from  social  and  economic  reasons  irre- 
spective of  health,  and  reform  will  come,  though  perhaps  slowly,  that  will  make 
it  impossible  to  exploit  the  work  of  a  girl  who  has  not  reached  the  age  of 
puberty.  The  special  dangers  to  health  of  various  individual  occupations  can- 
not be  taken  up  here.  Considerable  experience  with  working  girls  demon- 
strates that  the  ill  effects  upon  health  due  to  external  conditions  are:  (1)  Long 
confinement  in-doors  in  superheated,  badly  ventilated,  dirty  rooms ;  ( 2 )  work 
permitting  little  change  of  posture  and  enforcing  either  long-continued  sitting 
or  standing;  (3)  contact  with  unhealthy  work  companions  suffering  from 
tuberculosis  or  other  infectious  diseases.  These  conditions  are  common  to  the 
poorly  paid  unskilled  laborer  and  to  the  skilled.  Clerks  in  offices  and  teachers 
in  schools  are  often  under  worse  conditions  for  their  health  than  factory  girls. 
The  remedy  for  these  conditions  will  never  be  effective  until  all  places  of 
employment  for  women  are  under  rigid  inspection  of  a  competent  health  depart- 
ment with  power  to  enforce  sanitary  conditions.  This  inspection  should  eventu- 
ally include  employment  at  home  and  conditions  under  which  domestic  servants 


HYGIEIVTE    OP    OCCUPATIO]Sr.  75 

live.  Among  the  various  results  that  have  grown  out  of  the  campaign  against 
tuberculosis  has  been  the  institution  by  great  employers  of  labor  here  and  there 
throughout  the  country  of  the  physical  examination  of  employees  in  industrial 
establishments.  There  is  every  reason  to  look  for  a  gradual  extension  of  medi- 
cal inspection  to  all  those  who  work  in  close  contact  with  each  other,  with  the 
resulting  improvement  in  personal  and  general  hygiene  which  always  follows 
systematic  medical  inspection  of  special  classes. 

The  health  of  the  working  girl  suffers  too  often  from  faults  of  personal 
hygiene.  Malnutrition  due  to  insufficient  and  improper  food  is  among  the 
most  frequent  causes  of  ill  health.  Either  no  breakfast,  or  a  hasty  breakfast 
of  bread  with  coffee  or  tea,  no  luncheon  or  an  insufficient  one^  with  fatigue 
often  so  gTeat  that  no  supper  is  eaten,  is  a  frequent  history  of  these  cases,  if  the 
physician  persists  in  getting  at  the  personal  habits.  Coffee  and  tea  may  be  the 
chief  dietary.  Tonics  prescribed  for  the  working  girl  who  needs  food,  and 
recreation  out-of-doors  give  little  result.  Many  working  girls  spend  money 
for  drugs,  jDrescribed  by  physicians,  pharmacists,  and  friends  that  ought  to 
be  used  for  buying  food.  The  education  of  the  working  girl,  too,  as  to  the 
relation  of  food  to  energy,  and  of  the  kind  and  quantity  of  food  she  needs 
is  important,  but  the  kind  of  food  she  needs  must  be  easy  to  get,  or  she  goes 
without  it. 

Constipation,  too  few  hours  of  sleep,  and  these  spent  in  rooms  occupied 
by  several  others,  with  no  ventilation,  are,  with  faulty  diet,  and  unhygienic 
clothing,  the  principal  causes  of  bad  health  among  working  girls 'which  they 
can,  in  a  measure,  control.  In  so  far  as  her  occupation  increases  these  faulty 
habits  common  to  rich  and  poor  alike,  so  far  her  occupation  is  responsible  for 
her  ill  health,  in  addition  to  the  bad  environment  of  shop  and  factory.  Shorter 
hours,  with  encouragement  in  simple  out-door  recreations,  and  more  ample  pro- 
vision for  these  would  bring  about  great  improvement  in  the  average  health  of 
the  working  girl. 

Influence  of  Social  Life  upon  the  Health  of  Women. — The 
life  of  the  young  woman  of  the  leisure  classes  whose  school  education  is  com- 
pleted at  sixteen  or  seventeen  is  too  often  distinctly  unfavorable  to  her  health. 
It  is  tacitly  understood,  though  not  always  consciously  expressed,  that  for  four 
or  five  years  her  main  function  is  to  make  herself  attractive  and  to  enjoy  life, 
acquiring  irregularly  and  incidentally  some  knowledge  of  the  management  of 
a  household.  Her  standards  of  attractiveness,  and  her  standards  of  pleasure 
usually  have  no  hygienic  basis.  The  exactions  of  an  active  social  career  under 
the  most  favorable  conditions  are  unquestionably  a  source  of  excessive  physical 
and  emotional  fatigue.  Indolence  alternates  with  over-stimulation,  intellec- 
tual activity  is  in  abeyance,  the  desire  for  entertainment  and  excitement  is 
insatiable,  physical  exercise  is  irregular,  lacking,  or  excessive,  and  clothes  are 
used  for  ornament  according  to  the  dictates  of  fashion  without  considering  the 
needs  of  the  body.  The  necessity  for  rest  and  for  sleep  is  disregarded.  The 
poor  try  to  keep  pace  with  the  rich.     It  is  in  this  exclusively  social  life  that  the 


76  HYGIENE    OF    INFANCY    AND    GIRLHOOD. 

foundation  is  often  laid  for  the  ill  health  of  adult  women  which  is  frequently 
and  carelessly  attributed  to  '*  over-education." 

Influence  of  College  Life  ui)on  the  Health  of  Women. — The 
effect  of  college  education  upon  the  health  of  women  has  been  the  subject  of 
much  discussion  in  medical  and  in  general  literature.  These  discussions  have 
been  obscured  usually  by  the  loose  way  in  which  the  phrase  "'higher  educa- 
tion "  has  been  used  to  desig-nate  any  kind  of  school  education  from  the  high 
school  to  the  university.  It  seems  now  generally  conceded  that  as  much  edu- 
cation as  a  girl  may  get  in  the  schools  before  her  seventeenth  year  is  not  only 
not  harmful,  but  if  given  under  proper  conditions,  is  distinctly  favorable  to 
her  health.  An  examination  of  the  arguments  upon  which  injury  to  health  of 
women  is  predicated  as  a  result  of  education  beyond  the  high  school  finds  them 
based  upon  the  hypotheses:  (1)  That  mental  activity  is  in  itself  harmful  to 
the  health  of  women  (this  in  recent  years  is  not  often  suggested)  ;  (2)  that 
emotional  stress  and  strain  represented  by  worry  and  anxiety  necessarily  accom- 
pany the  conditions  of  college  life,  and  bring  about  such  interference  with  gen- 
eral nutrition  as  to  produce  permanent  injury,  showing  itself  principally  in 
some  failure  of  the  reproductive  organs  manifested  by  menstrual  disturbances, 
or,  after  marriage,  by  sterility,  or  failure  in  the  function  of  lactation.  Statis- 
tics have  been  collected  designed  to  show  that  college  life  has  serious  effects 
upon  the  menstrual  function,  upon  rate  of  marriage,  and  upon  the  production 
of  children. 

The  fallacy  of  the  statistical  method  and  the  method  of  the  questionnaire 
as  bearing  upon  the  subject  involved  is  easy  of  demonstration,  but  cannot  be 
discussed  here.  That  a  childless  marriage,  however,  or  a  small  family  always 
indicates  either  sterility  on  the  part  of  a  woman,  or  lack  of  desire  to  bear  chil- 
dren is  an  untenable  proposition,  though  one  that  too  often  passes  without  chal- 
lenge in  current  literature.  Any  physician  who  has  had  wide  and  intimate 
acquaintance  with  college  women  knows  that  they  do  not  evade,  on  the  con- 
trary, they  welcome  the  duties  and  responsibilities  of  married  life,  and  bring 
to  their  performance  mental  and  physical  attributes  from  which  society  and 
the  race  may  profit. 

Obviously,  the  effect  of  college  life  upon  the  health  of  the  individual  girl 
can  be  determined  only  by  a  knowledge  of  her  physical  condition  at  entrance, 
her-  personal  and  family  history,  her  hygienic  habits,  the  exactions  of  college 
life,  as  well  as  by  continued  medical  observation  during  her  course,  together 
with  a  medical  knowledge  of  her  subsequent  history.  If  one  college  com- 
munity, drawing  its  students  from  all  parts  of  the  country,  may  be  taken  as 
fairly  representative,  it  may  be  confidently  stated  that  conditions  of  college 
life  are  distinctly  favorable  to  the  health  of  young  women.  In  a  long  series 
of  observations  in  one  such  community  not  a  single  instance  of  nervous  break- 
down or  chronic  ill  health  has  been  observed  in  which  the  legitimate  de- 
mands of  college  life  could  be  considered  an  essential  etiological  factor. 
This  point  may  be  illustrated  by  reference  to  the  frequently  quoted  statistics  of 


HYGIENE    OF    OCCUPATIOlSr.  77 

G.  W.  Engelmann,  apparently  showing  that  college  life  brings  about  menstrual 
disturbances.  In  the  first  place,  an  analysis  of  more  than  one  thousand  his- 
tories does  not  corroborate  his  figures.  Sixty-five  to  seventy  per  cent  of  college 
women  never  suifer  with  dysmenorrhea.  Taking  two  classes  giving  relatively 
high  percentages  for  dysmenorrhea  of  two  hundred  and  thirty-two,  sixty-five, 
or  twenty-eight  and  two-hundredths  per  cent,  had  some  menstrual  disturbance 
when  they  entered  college ;  of  these,  only  thirty-two,  or  thirteen  and  seventy- 
three  hundredths  per  cent,  had  sufficient  dysmenorrhea  to  require  a  day's  rest 
at  each  period.  JSTine  of  these  were  otherwise  healthy  girls  that  no  stretch  of 
imagination  could  have  regarded  as  injuring  themselves  by  mental  and  physical 
over-exertion.  Among  these  nine  was  the  only  girl  in  whom  dysmenorrhea 
increased  during  her  college  course,  and  in  no  single  case  was  it  necessary  to 
consider  that  college  work  had  any  causative  relation  to  the  dysmenorrhea. 

For  the  girl  with  fair  health  who  can  enter  college  "  without  conditions  " 
there  is  nothing  to  fear  and  much  to  be  gained  by  prolonging  education  through 
a  four  years'  course.  Why  should  it  be  unhealthful?  The  girls  have  regular, 
systematic  employment.  They  have  the  mental  satisfaction  which  comes  from 
accomplishing  definite,  progressive  work.  The  wide  elective  system  makes 
their  intellectual  effort  pleasurable,  since  they  may  choose  what  interests  them 
and  satisfies  their  desires.  Mental  work  alternates  with  physical  exercise. 
Their  food  is  well  chosen.  Their  hours  of  rest  and  of  sleep  are  usually  regu- 
lated with  intelligence.  They  have  congenial  companionship,  and  they  are, 
for  the  most  part,  contented  and  happy. 

General  Summary. — The  great  function  of  woman  is  to  bear  and  to  rear 
children.  The  primary  requisite  for  this  is  a  healthy  body.  To  rear  children 
women  need  intelligence.  Good  health  and  intelligence  are  not  incompatible. 
Whatever  in  a  final  analysis  may  be  shown  to  interfere  with  a  woman's  physical 
capacity  to  bear  children,  or  her  ability  to  rear  them  is,  for  her,  unhygienic. 

The  health  of  the  growing  girl  is  a  result  of  her  heredity  and  her  environ- 
ment. Her  heredity  will  be  more  favorable  when-  public  opinion  makes  good 
health  in  men  and  women  a  primary  element  of  attractiveness,  and  hence 'an 
important  factor  in  sexual  selection.  Her  environment,  represented  by  the 
family,  the  school,  and  the  community,  will  be  more  favorable  when  the  family 
secures  and  applies  a  better  knowledge  of  personal  hygiene,  especially  of  food 
and  its  relation  to  health,  growth,  and  energy ;  when  the  school  possesses  and 
applies  a  better  knowledge  of  the  physiology  of  fatigue,  physical  and  mental; 
when  the  community  acquires  and  applies  a  better  knowledge  of  infectious 
diseases  and  the  means  for  their  prevention. 


CHAPTER  III. 

NORMAL  MENSTRUATION  AND  THE  MENOPAUSE. 

(1)  Normal  menstruation:  Theories,  p.  78.     Mechanism,  p.  80.     Age  of  first  menstruation,  p.  82. 

Duration  of  menstruation,  p.  83.     Amount,  p.  85.     Interval  between  periods,  p.  85. 

(2)  Menopause:  Age,  p.  87.     SjTiiptoms,  p.  88.     Local  changes  in  genital  organs,  p.  88.     Hemor- 

rhage, p.  88.     Vaginal  discharges,  p.  89.     Care  of  general  health,  p.  89. 

NORMAL    MENSTRUATION. 

Theories. — Menstruation  is  a  term  used  to  characterize  a  discharge  of  bloody 
fluid  which  takes  place  from  the  uterus  at  stated  periods  throughout  the  time 
of  sexual  activity  in  the  life  of  women.  This  definition  makes  no  attempt  to 
deal  with  the  etiology  of  menstruation,  because,  though  this  has  been  the  subject 
of  speculation  for  many  years,  our  knowledge  in  regard  to  it  is  still  quite 
incomplete. 

An  understanding  of  the  true  nature  of  menstruation  presents  certain  pecul- 
iar difficulties,  arising  from  the  fact  that  menstruation  is  confined  to  human 
beings  and  some  of  the  higher  apes,  so  that  the  method  of  investigation  usual 
in  physiological  research,  animal  experimentation,  is  not  easily  available.  It 
would  not  be  profitable  to  enter  here  upon  any  detailed  discussion  of  all  the 
differing  theories  of  menstruation;  I  shall,  therefore,  content  myself  with  a 
brief  account  of  three,  which  seem  to  me  especially  worthy  of  attention. 

Two  opposing  hypotheses  have  coexisted  for  a  number  of  years.  One  of 
these,  of  which  the  chief  exponents  are  Pfliiger  and  Bischoff,  holds  that  men- 
struation is  dependent  upon  ovulation  and  coincident  with  it.  According  to 
this  view,  the  Graafian  follicle,  by  its  swelling  during  its  development,  excites 
nerve  impulses,  which,  being  reflected  upon  the  vaso-motor  system,  give  rise 
to  local  congestion.  The  congestion  involves  both  the  uterine  and  ovarian 
circulations  and  in  the  end  produces  a  hemorrhage  from  the  uterine  mucous 
membrane  as  an  accompaniment  to  the  liberation  of  the  ovum  from  its  follicle. 
This  theory  has  been  modified  by  Reichert  and  others,  who  hold  that  the  hem- 
orrhage which  constitutes  menstruation  takes  place  because  the  ovum  discharged 
prior  to  its  occurrence  is  not  impregnated,  and,  in  the  absence  of  any  stimula- 
tion to  further  gTowth  towards  the  formation  of  the  decidua  of  pregnancy,  a 
retrograde  metamorphosis  takes  place  in  the  uterine  mucous  membrane,  accom- 
panied by  a  discharge  of  blood.  This  theory  seems  in  opposition  to  the  fact, 
observed  in  my  clinic,  that  with  the  discharge  of  blood  the  mucosa  reaches  its 
fullest  development. 
78 


THEORIES    OF    MENSTBUATIOK.  79 

The  opposite  view,  of  which  Kiegel  is  the  chief  exponeiat,  maintains  that 
ovulation  and  menstruation  are  tv/o  entirely  independent  functions ;  that  the 
discharge  of  the  ovum  may  take  place  at  any  time  and  without  any  reference 
to  the  act  of  menstruation.  In  support  of  this  theory  it  is  urged  that  men- 
struation sometimes  continues  after  the  removal  of  both  ovaries;  and  further, 
that  conception  has  been  known  to  take  place  in  women  who  have  never  men- 
struated, or  have  done  so  only  a  few  times,  at  periods  remote  from  conception. 
Moreover,  as  I  have  seen  in  many  instances,  women  sometimes  pass  from  one 
pregnancy  to  another  without  menstruation.  Some  of  these  objections  the 
supporters  of  the  opposite  view  answer  by  calling  attention  to  the  fact  that 
menstruation  after  the  removal  of  the  ovaries,  persists,  in  almost  every  instance, 
for  but  a  few  months,  and  can  then  be  explained  by  long-established  habit.  In 
the  cases  where  it  has  continued  permanently,  there  is  good  reason  to  believe 
that  some  ovarian  tissue  has  been  left  behind ;  it  is  never  due  to  a  mythical 
third  ovary.  An  argument  of  much  greater  significance  is  the  occasional  occur- 
rence of  conception  at  dates  known  to  be  independent  of  menstruation.  It  is 
possible,  however,  to  reconcile  the  two  conflicting  views  by  the  supposition  that 
although  menstruation  is  not  dependent  upon  ovulation,  some  relation  exists 
between  them  by  which  they  are,  as  a  rule,  coincident;  conception,  therefore, 
takes  place  in  the  majority  of  cases,  near  the  time  of  menstruation,  but  if  the 
relation  between  the  two  is  disturbed,  it  may  occur  at  some  date  entirely  unas- 
sociated  with  menstruation.  This  represents  the  point  of  view  held  by  some 
persons  at  the  present  time. 

In  addition  to  these  theories  as  to  the  relation  of  ovulation  and  menstrua- 
tion, a  new  view  was  promulgated  about  four  years  ago  by  L.  Frankel,  who 
claims  that  the  act  of  menstruation  is  governed  by  the  corpus  luteum.  Frankel, 
in  his  account  of  his  theory,  ascribes  the  idea  to  Gustav  Born,  who  reckoned 
the  corpus  luteum  among  the  secreting  glands  and  attributed  to  it  the  func- 
tion of  stimulating  the  uterine  mucous  membrane  to  receive  the  ovum  and 
foster  its  further  development.  Frankel,  in  considering  this  view,  reached  the 
conclusion  that  if  it  were  true,  the  influence  of  the  corpus  luteum  over  the 
implantation  of  the  ovum  (nidification)  is  only  one  part  of  a  much  more 
extended  function,  and  he  instituted  investigations  along  this  line. 

He  first  proved  by  experiments  on  rabbits  that  if  the  corpus  luteum  was 
destroyed  by  means  of  the  galvano-cautery  shortly  after  the  ovum  was  fertilized, 
the  ovum  failed  to  enter  the  uterus,  or,  if  the  destruction  was  delayed  until  the 
ovum  had  had  time  to  enter  the  uterus,  it  failed  to  develop.  A  further  set  of 
experiments  showed  that  destruction  of  the  corpus  luteum  was  accompanied  by 
atrophy  of  the  uterus,  one  process  being  in  direct  proportion  to  the  other.  If, 
as  these  experiments  seem  to  demonstrate,  the  corpus  luteum  is  responsible  for 
the  nutrition  of  the  uterus,  and,  incidentally,  for  the  attachment  and  develop- 
ment of  the  ovum,  the  next  question  in  logical  sequence  is :  What  is  the  relation 
of  the  corpus  luteum  to  menstruation?  If  destruction  of  the  corpus  luteum 
occasions  atrophy  of  the  uterus,  it  ought  to  cause  suppression  of  menstruation. 


80  XOEMAL    :MEXSTErATIOX    AXD    THE    MEXOPAUSE. 

In  order  to  elucidate  this  point,  Frankel  made  nse  of  certain  celiotomies, 
performed  for  such  purposes  as  ventro-fixation  when  the  pelvic  organs  were 
healthy.  In  nine  such  cases  he  destroyed  the  corpns  Inteum  and  waited  to 
observe  the  effect  npon  the  next  menstruation.  In  five  ont  of  the  nine,  men- 
struation was  completely  suppressed  for  a  period  varying  from  three  to  eight 
weeks  after  the  time  at  which  it  was  expected.  In  three  of  the  remaining  four 
cases,  there  was  a  slight  bloody  discharge  from  the  genitalia  a  few  days  after 
the  operation,  which  the  patients  themselves  interpreted  as  menstruation; 
Frankel,  however,  thought  it  more  probable  that  it  was  nothing  more  than  the 
bloody  discharge  accompanied  bj  pelvic  pain  which  is  often  observed  after 
abdominal  operations  of  any  kind,  especially  as  in  each  instance  the  regular 
menstrual  period  did  not  appear  at  the  expected  time,  being  delayed  until 
eight  weeks  after  the  operation.  In  only  one  case,  therefore,  out  of  the  nine, 
was  menstruation  unaffected,  and  a  single  negative  instance  out  of  so  large  a 
number  can  probably  be  explained  by  some  special  circumstance.  Frankel, 
indeed,  suggests  several  reasons  for  the  exception;  for  instance,  the  corpus 
luteum  may  not  have  been  entirely  destroyed ;  or  there  may  have  been  a  double 
ovulation ;  or  the  secretory  activity  of  the  corpus  luteum  had  already  proceeded 
so  far  that  the  necessary  stimulus  to  menstruation  had  been  given. 

In  conclusion,  Frankel  oifers  the  following  suggestions  as  to  the  working 
of  his  theory :  The  uterus,  like  every  other  organ  in  the  body,  has  its  own  blood 
vessels,  both  afferent  and  efferent.  These  are  not  dependent  upon  the  corpus 
luteum  for  nutrition,  but  without  it  they  cannot  impart  the  life  energy  neces- 
sary to  induce  the  hyi^eremia  which,  if  the  ovum  is  fertilized,  leads  to  the  fur- 
ther phases  of  its  development,  or,  if  it  remain  unfertilized,  results  in  men- 
struation. 

Frankel  has  published  several  communications  upon  the  subject.  His 
principal  paper  ("  Die  Function  des  Corpus  luteum,"  Arch.  f.  Gyn.,  1903, 
vol.  68,  p.  -i38)  is  a  long  and  interesting  one.  It  gives  his  experiments 
in  detail  and  contains  some  thoughtful  speculations  on  the  relation  between 
pathologic  conditions  of  the  corpus  luteum  and  certain  morbid  conditions 
of  the  uterus  and  its  appendages,  such  as  extra-uterine  pregnancy,  ovarian 
tumors,  and  some  inexplicable  cases  of  sterility.  This  interesting  theory,  so 
attractive  at  first  sight,  is  being  widely  tested,  but  is  as  yet  far  from  being 
substantiated. 

Mechanism. — The  mechanism  of  menstruation,  as  Hirst  says,  is  better 
understood  than  the  causation.  The  process  of  menstruation  consists  mainly 
of  a  diapedesis  of  blood  through  delicate  capillaries,  newly  formed  in  a  thick- 
ened and  congested  endometrium,  the  provision  for  carrying  blood  to  the  mem- 
brane being  better  than  that  for  carrying  it  away.  Some  of  the  newly-formed 
and  delicate  capillaries  rupture  and  a  discharge  takes  place.  Leopold  has 
given  the  following  description  of  the  condition  of  the  uterine  mucous  mem- 
brane during  menstruation: 

"  The    mucous    membrane    is    8    mm.     (0.315    in.)    thick,    swollen,    dark 


MECHANISM    OF    MENSTRUATION. 


81 


brownish-red,  soft  almost  to  liquefaction,  but  perfectly  intact,  and  sepa- 
rated by  a  sharply  defined  boundary  line  from  the  paler  muscular  tissue 
of  the  uterus.     The  uterine  glands,  which  are  0.5  to  0.75  mm.    (0.0197  to 

0.0296  in.)  wide,  are  considerably  lengthened 
and  can  be  seen  by  the  naked  eye.  In  the 
superficial  portion  of  the  mucous  membrane, 
which  is  well  preserved  and  only  in  certain  spots 
lacks  its  epithelium  and  adjacent  cells,  may  be 
^  S^  Ho  (  In  "  s^en  an  immense  and  enormously  hypertrophied 
)A^     7)  o     y  li  I  a         capillary    net-work,    the    vessels    of   which    have 

irregular  outlines  and  lie  in  the  uppermost 
layer  of  the  mucous  membrane."  (Quoted  by 
Hirst,    "  Diseases    of    Women,"    second    edition, 

1905.)  Figure  51  shows 
the  changes  taking  place 
in  the  endometrium  near 
menstruation  (1)  as  com- 
pared with  its  normal 
condition  (2). 


o 


r^^r^ 


^  V- 


^^i4^  v| 


i 

e 

^  i 


1 


3 


Fig.  51. — (1)  Normal,  Endometrium  of  a  Patient  Twenty-six  Years  Old,  near  Menstruation, 
Magnified  Twenty-five  Diameters.  (2)  Normal  Endometrium  of  a  Patient  Forty-one 
Years  Old,  Magnified  Twenty-five  Times.  (3)  Endometrium  after  Menopause,  Magni- 
fied Fifty  Times.     T.  S.  Cullen,  "Cancer  of  the  Uterus." 


Veit,  as  a  result  of  a  study  of  the  uterus  during  menstruation,  divides  the 
changes  taking  place  into  three  periods: 

( 1 )  Premenstrual  congestion,  in  which  the  capillaries  are  distended ;  there 
is  a  transudation  or  exudation  of  blood  into  the  intercellular  tissues,  the  meshes 
of  which  are  widened,  and  an  accumulation  of  blood  under  the  sub-epithelium, 
which  is  raised  into  little  hillocks  by  the  sub-epithelial  hematomata. 

(2)  Escape  of  the  accumulated  blood  through  the  interstices  between  the 
epithelial  cells,  which  are  pushed  apart;  some  of  them  may  be  carried  away 

7  .  .  - 


82  NORMAL    MEXSTEUATIOX    AND    THE    MENOPAUSE. 

by  the  blood  as  it  forces  its  way  out.  There  is  also  some  desquamation  of  the 
glandular  epithelium. 

(3)  Post  menstrual  involution,  in  which  the  mucosa  shrinks  and  the 
extravasated  blood  remaining  in  the  intercellular  tissue  is  absorbed.  The  sur- 
face epithelium,  lifted  awaj  from  its  subjacent  tissue  sinks  again  to  its  normal 
level  ("Handbuch  der  Gynakologie,"  Bd.  III). 

The  gross  changes  taking  place  in  the  genital  organs  are  those  belonging  to 
congestive  conditions  elsewhere  in  the  body.  The  uterus,  ovaries,  tubes,  and 
vagina  are  swollen  and  darkened  in  color.  The  uterus,  in  particular,  is  en- 
larged in  size,  the  mucous  membrane  is  thro^^^l  into  folds,  and  the  cervix  is 
softened. 

At  the  beginning  of  menstruation,  the  flow  is  composed  of  mucus  streaked 
with  blood,  but  when  menstruation  becomes  established,  the  discharge  consists 
of  pure  blood  mixed  with  a  little  mucus  and  epithelial  cells  from  the  nterine 
cavity  and  the  vagina.  As  the  flow  subsides  it  returns  again  to  its  mucous 
character.  Menstrual  blood  is  dark  in  color,  alkaline  in  reaction,  and,  owing 
to  the  presence  of  mucus,  it  does  not  coagulate  unless  it  is  excessive  in 
amount. 

Age  of  First  Menstruation. — The  age  at  which  menstruation  first  takes  place 
is  given  by  difi^erent  authorities  at  from  twelve  to  fifteen.  The  following 
averages  are  taken  from  different  text-books  on  gjTiecology:  Ashton,  twelve 
to  fourteen;  Garrigues,  thirteen  to  fourteen;  Hart  and  Barbour,  thirteen  to 
fifteen;  Hirst,  fourteen;  Emmet,  fourteen;  Montgomery,  twelve  to  fourteen; 
Penrose,  thirteen;  Gilliam,  thirteen.  Cases,  however,  are  sometimes  met 
with  in  which  it  occurs  below  or  above  the  extremes  of  these  averages,  with- 
out being  in  the  slightest  degree  remarkable.  Anything  below  ten  or  above 
twenty,  however,  must  be  considered  abnormal.  Cases  of  precocious  men- 
struation are  nevertheless  constantly  being  reported,  and  Strassmann  has  col- 
lected fifteen  instances  where  it  appeared  during  the  first  year  of  life.  It 
must  always  be  borne  in  mind  that  precocious  menstruation  is  frequently  the 
manifestation  of  some  morbid  condition  of  the  uterus  or  its  appendages,  such 
as  ovarian  tumors,  myomata,  and  affections  of  the  endometrium.  Kiedl  has 
recently  reported  a  case  in  which  menstruation  began  at  two  years  old  and  con- 
tinued regularly  up  to  six  years,  when  the  child  came  under  observation.  Ex- 
amination of  the  external  genitalia  showed  the  mons  veneris  to  be  covered  with 
hair,  as  well  as  the  labia,  which  were  well  developed.  The  vaginal  outlet 
admitted  the  index  finger.  On  opening  the  abdomen  a  round-celled  sarcoma 
of  the  left  ovary  which  weighed  two  and  a  half  kilogrammes  (about  five  and  a 
haK  pounds)  was  found  and  removed.  The  right  ovary  was  small  in  size  and 
contained  a  few  cysts.  The  uterus  was  as  large  as  that  of  a  girl  of  seventeen. 
Early  menstruation,  unaccounted  for  by  local  lesions,  is  usually  the  indication 
of  vigorous  sexual  activity,  which  will  probably  extend  over  a  prolonged  period, 
so  that  in  cases  where  menstruation  is  established  under  the  average  age,  its 
cessation  will,  in  all  probability,  be  correspondingly  late. 


AGE    OF    FIRST    MENSTRUATION.  83 

The  most  complete  treatment  of  the  subject  is  by  the  late  George  J.  Engel- 
mann  ("  Age  of  First  Menstruation  on  the  !North  American  Continent,"  Trans. 
Amer.  Gyn.  Soc,  1901,  vol.  26,  p.  77).  The  conclusions  reached  are  based 
on  12,402  observations  of  his  own,  made  upon  women  of  American  birth, 
although  in  many  instances  of  foreign  parentage,  covering  the  territory  from 
Canada  to  all  but  the  most  extreme  of  the  Southern  States.  To  these  are  added 
5,955  observations  upon  white  women  and  negresses,  made  by  others;  to  which 
he  adds  certain  data  touching  the  semi-civilized  races  on  this  continent  (In- 
dians and  Esquimaux),  making  a  total  of  19,405  observations  upon  American- 
born  women.  The  12,402  observations  made  by  Engelmann  himself  represent 
all  phases  of  temperature  and  climate  from  the  subarctic  conditions  of  north- 
ern Canada  to  the  almost  tropical  environment  of  jSTew  Orleans,  and  from  the 
Atlantic  coast  to  the  Mississippi  valley.  In  parentage  they  cover  a  number 
of  nationalities,  including  English,  Irish,  German,  and  Erench,  only  those 
most  commonly  met  with  being  given.  The  conclusions  drawn  as  regards  Amer- 
ican-born women  are,  briefly,  as  follows : 

The  age  of  first  menstruation  in  the  American-born  woman  on  this  conti- 
nent is  14.3  for  the  laboring  classes,  such  as  are  seen  in  free  dispensaries; 
and  14.2  for  the  educated  classes,  seen  in  private  practice.  The  writer  con- 
cludes by  saying,  "  Climate  has  practically  no  influence  ;  race  very 
little  ;  mentality,  surroundings,  education,  and  nerve  stimula- 
tion stand  out  prominently  in  this  country  as  the  factors  which  deter- 
mine   precocity." 

There  seems  to  be  little,  if  any  difference,  between  girls  of  foreign  parentage 
and  those  who  have  had  American  progenitors.  It  is  well  known,  of  course, 
however,  that  there  exists  a  wide  difference  between  countries  as  to  the  age  of 
first  menstruation.  Eor  example,  it  occurs  at  the  age  of  eighteen  in  the  girls 
of  Lapland  and  at  eight  to  ten  in  the  aborigines  of  Australia  and  in  the  natives 
of  Southern  Prussia,  Egypt,  Servia,  and  Sierra  Leone.  It  has  always  been 
customary  to  ascribe  this  difference  between  nationalities  entirely  to  the  cli- 
matic effect  of  heat  in  hastening  puberty,  and  of  cold  in  retarding  it.  Cer- 
tainly the  evidence  in  the  main  supports  this  idea.  That  there  is  something 
to  be  said,  however,  in  favor  of  the  view  that  race  as  well  as  climate  may  be 
concerned,  may  be  deduced  from  the  fact  that  the  Esquimaux  of  Alaska,  where 
certainly  climatic  conditions  are  of  a  nature  to  retard  rather  than  to  accelerate 
development,  menstruate  at  the  age  of  thirteen. 

xis  regards  our  own  countrywomen,  Engelmann's  statistics  indicate  four- 
teen years  as  the  average  age  for  the  appearance  of  menstruation.  An  impor- 
tant predisposing  factor  in  fixing  the  age  in  any  given  case,  however,  is  the 
customary  time  for  the  family.  It  is  always  well,  therefore,  to  inquire  at  what 
age  the  mother  began  to  menstruate. 

Duration. — The  length  of  the  menstrual  period  varies  considerably  in  dif- 
ferent persons.  When  once  the  individual  standard  is  established,  however, 
it    should   remain   fixed,    and    any    marked    or    prolonged    variation   from    it 


84 


NORMAL  MEXSTRUATION  AXD  THE  MENOPAUSE. 


is  generally  associated  Avitli  a  failure  of  general  health,  although  it  does  uot 
necessarily  imply  the  presence  of  a  local  lesion.  Authorities  differ  as  regards 
the  limits  of  the  menstrual  period,  and  I  quote  the  opinions  expressed  in  sev- 
eral well-kno^^-n  text-books :  Ashton,  three  to  six  days ;  Garrigues,  four  days ; 
Hart  and  Barbour,  two  to  eight  days ;  Hirst,  three  to  seven  days ;  Mont- 
gomery, two  to  eight  days ;  Penrose,  two  to  seven  days ;  Gilliam,  four  to  five 
days.  In  all  these  cases  the  statement  is  made  didactically  and  no  statistics 
are  given,  nor  have  I  found  any  figures  npon  the  subject  except  in  the  case 
of  Emmet,  who  goes  into  the  subject  in  great  detail  and  gives  four  to  five 
days  as  the  general  average.  I  have  collected  and  tabulated  one  thousand 
cases  from  my  private  case-books,  taking,  of  course,  only  the  history  of  men- 
struation under  its  normal  conditions,  before  it  had  been  affected  by  the  abnor- 
mal conditions  for  which  I  was  consulted.     I  eive  these  results  in  tabular  form. 


TABLE  SHOWING  DURATION  OF  MENSTRUATION   IN    1,000  CASES. 


1  day. 
1-3  days 

2 
2-4 

3 
3-5 

4 


15 
15 
36 
59 

105 
85 

115 


Total. 


112 
136 
83 
68 
37 
122 
12 


1,000 


It  will  be  seen  that  the  limits  in  this  table  are  twenty-four  hours  and  seven 
to  eight  days.  All  authorities  I  have  consulted  make  the  shortest  duration 
two  days,  but  the  number  of  my  cases  which  lasted  only  one  day  seemed  to 
me  quite  large  enough  to  warrant  taking  this  as  my  lowest  limit.  Again, 
some  gynecologists  make  the  upper  limit  eight  days ;  my  experience,  how- 
ever, leads  me  to  agree  with  those  who  consider  anything  over  a  week  as 
abnormal.  It  is  so  common,  however,  to  find  menstruation  prolonged  a  trifle 
beyond  its  last  complete  day  that  I  have  included  cases  lasting  into  the 
eighth  day. 

While  collecting  these  cases,  my  attention  was  attracted  by  the  fact  that  in 
many  of  those  in  which  menstruation  lasted  over  six  days,  it 
was  noted  that  the  flow  was  more  or  less  in  excess  of  the  normal. 
I  made  a  second  analysis,  therefore,  of  200  cases  in  which  the  duration  of  the 
flow  was  over  six  days,  and  I  found  that  in  52  of  them  it  was  noted  as  free, 
while  in  68  it  was  excessive;  the  whole  number  in  which  it  was  in  excess  of 
normal  being  120,  or  six-tenths  of  the  whole.  This  appears  to  me  strongly 
suggestive  of  the  fact  that  a  duration  of  more  than  six  days  is  so 
frequently  pathologic  that  it  should  never  be  regarded  as  normal, 
unless  it  is  clear  from  other  data  that  the  patient's  health  is  fully 
up    to    par.     If  she  is  anemic,  or  shows  evidence  of  malnutrition  by  failure 


INTERVAL    BETWEEN    MENSTRUAL    PERIODS.  85 

of  appetite,  or  of  strength,  or  of  weight,  menstruation  is  probably  in  excess  of 
normal,  even  though  it  has  not  occurred  to  her  or  her  relatives  that  there  is 
anything  amiss. 

This  is  the  class  of  cases  in  which  such  marked  improvement  follows  a 
simple  curettage,  for  the  performance  of  which  there  has  seemed  but  little 
local  indication. 

Exclusive  of  cases  such  as  these,  where  an  excessive  flow  has  become  estab- 
lished so  insidiously  or  so  early  as  to  be  accepted  as  normal,  the  duration  of 
the  menstrual  period  which  is  habitual  may  be  regarded  as  the  proper  standard 
for  the  individual  woman,  and  if  her  health  does  not  deteriorate,  it  usually 
remains  unchanged  through  life. 

Amount. — The  amount  of  blood  lost  at  each  menstrual  period  is  extremely 
difficult  to  estimate,  and  cannot,  indeed,  ever  be  determined  with  real  accuracy. 
Different  authorities  give  it  as  varying  from  two  to  eight  ounces  (60  to  240 
c.c).  The  usual  rough  way  of  estimating  it  by  the  number  of  protectives 
needed  is  too  unreliable  to  be  any  guide  as  to  the  actual  amount  lost,  although 
it  is  a  fairly  good  way  of  determining  an  increase  or  diminution  in  any  indi- 
vidual case.  Most  of  the  blood  is  lost  during  the  first  two  days  of  menstrua- 
tion, whatever  may  be  the  length  of  the  period.  For  the  first  few  menstrual 
periods,  before  the  function  is  well  established,  the  amount  often  varies  con- 
siderably, being  excessive  at  one  period  and  scanty  at  another,  but  in  the  course 
of  a  few  months,  as  a  rule,  a  standard  will  become  fixed,  and  this  should  remain 
undisturbed  during  the  remainder  of  menstrual  activity.  The  sigTiificance  of 
variations  from  the  established  standard  in  the  direction  of  either  excess  or 
decrease  will  be  considered  in  Chapters  VI  and  VII.  I  will  only  say  here  that 
any  deviation  from  the  normal  which  lasts  more  than  a  short  time  should  be 
brought  to  the  attention  of  a  physician,  who  is  the  only  person  qualified  to 
judge  of  its  real  importance.  Variations  from  the  normal  in  amount  or  dura- 
tion are  of  much  more  conseqlience  than  those  which  take  place  in  the  inter- 
vals between  the  menstrual  periods. 

Interval  Between  Periods. — In  normal  menstruation  there  is  far  less  indi- 
vidual variation  in  the  intervals  between  the  periods  than  in  either  their  dura- 
tion or  amount.  From  time  immemorial  twenty-eight  days  has  been  accepted 
as  the  standard  fixed  by  nature,  for  which  reason,  no  doubt,  it  has  always  been 
believed  among  uncivilized  people  that  the  periodicity  of  menstruation  depends 
upon  the  phases  of  the  moon.  In  this  instance  statistics  agree  with  common 
belief  more  closely  than  is  often  the  case,  and  they  show  beyond  any  question 
that  the  large  majority  of  women  menstruate  at  intervals  of  four  weeks;  there 
is,  however,  an  appreciable  number  who  do  so  at  longer  or  shorter  intervals.  I 
have  investigated  the  subject  by  collecting  and  analyzing  one  thousand  cases 
from  my  own  case-books,  with  the  following  results,  which  I  give  in  tabular 
form: 


86 


NOEMAL    MEXSTEUATIOX    AXD    THE    ME:S'0PAUSE. 


TABLE  SHOWING  INTERVAL  BETWEEN  MENSTRUAL  PERIODS  IN  1,000  CASES. 


21  davs 
22 


23 
23-25 

24 
24-25 

25 


TotaL 


22 
1 
6 
1 

6 
2 
9 


26 

days 

27 

28 

29 

30 

31 

35 

5 
1 

942 
1 
2 
1 
1 


1,000 


Various  Avriters  whom  I  have  consulted  give  twenty-eight  days  as  the  inter- 
val for  the  large  majority  of  cases,  but  they  do  not,  with  one  or  two  exceptions, 
enter  into  statistics.     The  exceptions  are : 

Krieger   ("Die  Menstruation,"  I.  D.  Berlin,  1869) 

28  davs 70     % 

30      "    13.7% 

27  "     1.4% 

Hart  and  Barbour   ("  Manual  of  Gynecology,"  1904). 

28  days 71     % 

30      '■     14     % 

21      "     2     % 

27  "     1  +  % 

Webster  ("Text-book  of  Diseases  of  Women,"  1907). 

28  days 71% 

30     "     14% 

The  preponderance  of  the  twenty-eight-day  type  is  the  same  in  all,  hut  it 
will  l)e  seen  that  in  my  list  the  next  highest  proportion  belongs  to  the  twenty- 
one-day  t^'pe,  which  in  Hart  and  Barbour's  list  is  the  third,  and  is  not  men- 
tioned at  all  by  the  others.  Where  the  proportion  is  so  excessive  in  favor  of 
any  one  type  it  would  require  statistics  covering  a  good  many  thousands  to 
establish  results  as  concerns  the  lower  percentages;  the  main  point,  however, 
remains  the  same  in  all,  namely,  that  twenty-eight  days  is  the  custom  for  so 
large  a  proportion  of  women  that  it  may  be  considered  as  the  established  rule, 
although  there  are  constant  exceptions  to  it  within  the  limits  of  health. 

The  interval  between  the  periods  is  sometimes  irregiilar  for  a  little  while 
after  menstruation  is  first  established ;  indeed,  there  is  a  general  impression, 
not  only  among  the  laity,  but  among  medical  men  that  it  is  usually  the  case. 
Emmet  found,  however,  that  out  of  2,447  women,  72.33  per  cent  were  reg-ular 
from  the  first;  18.92  per  cent  after  a  certain  period;  while  8.74  per  cent  were 
never  regular  ("Principles  and  Practice  of  Gynecology,"  3d  edition,  1884, 
p.  147). 

Strict  adherence  to  individual  habit,  as  I  have  said,  is  not  so  closely  asso- 
ciated with  health  as  it  is  to  the  duration  of  the  flow  or  to  its  amount,  and  even 
after  regularity  is  established,  variations  of  a  day  or  two  in  anticipation  or 
delay  are  very  frequent  and  need  excite  no  apprehension. 


MENOPAUSE.  87 


MENOPAUSE. 


Introductory. — Menarche  and  menopause  are  technical  terms  used  to  desig- 
nate respectively  the  beginning  and  cessation  of  the  menstrual  life  in  women, 
the  beginning  and  the  end  of  a  period  of  reproductive  activity.  In  English  the 
terms  "  puberty  "  and  "  change  of  life  "  are  more  commonly  used  and  well  un- 
derstood by  the  laity.  With  the  menopause  the  woman  steps  out  of  those  cyclical 
changes  which  for  thirty  years  have  represented  the  sigTi  manual  of  her 
femininity,  nature's  signs  of  the  successive  maturation  and  periodical  casting 
off  of  the  ova,  and  a  constant  call  to  the  fulfilment  of  her  law  in  the  exercise 
of  the  reproductive  function.  It  is  by  pregnancy  and  lactation  alone  that 
the  monthly  cycle  of  changes  is  normally  interrupted  at  irregular  intervals 
for  periods  approximating  two  years — as  a  rule,  well  within  the  outer  confines 
of  this  thirty-year  period  and  avoiding  the  two  termini,  the  beginning  and 
the  end. 

The  menopause  marks  the  passing  of  the  reproductive  function,  and  with 
its  cessation  the  entrance  of  the  woman  upon  a  new  and  final  stage  of  her  exist- 
ence, two-thirds  already  past,  a  final  third  remains  to  be  accomplished  under  new 
conditions. 

The  "  change  of  life,"  as  it  is  fitly  called,  is  indeed  the  major  crisis  in  the 
life  of  an  adult  woman.  A  man  is  apt,  after  a  life  of  hard  work  (and  this 
applies  especially  to  our  business  men),  to  pass  through  a  sort  of  grand  cli- 
materic  in  his  early  sixties,  after  which  he  realizes  that  his  forces  are  abated, 
and  it  is  well  to  walk  quietly  in  shady  paths  as  the  sun  visibly  nears  its  horizon. 
Tor  a  woman  the  change  is  of  another  kind  and  at  an  earlier  period.  She 
meets  her  major  crisis  some  time  in  the  forties  or  early  fifties,  when,  with 
the  cessation  of  the  monthly  function,  she  realizes  that  the  fires  of  youth  are 
flickering,  that  there  will  be  no  more  babies  to  be  nursed,  and  her  life  is  freed 
henceforth  from  those  periodical,  oftentimes  burdensome  fluctuations  in 
health.  The  clock  which  was  wound  up  at  fifteen  has  run  for  thirty  years, 
sounding  its  four-weekly  cycles  and  regulating  the  affairs  of  her  domestic  and 
social  life.  With  the  change  she  becomes  matronly,  and  with  her  increased 
avoirdupois  and  years  of  experience  behind  her,  assumes  a  greater  dignity  and 
a  tone  of  authority  in  those  affairs  of  life  which  have  come  within  the  range  of 
her  activities.  It  is  at  this  period,  when  freed  from  the  many  trammels  of 
younger  womanhood,  that  she  often  enters  into  a  new  and  calm  enjoyment  of 
intellectual  occupations,  enters  more  into  society  and  finds  more  time  for  hus- 
band and  the  children  rapidly  growing  up  about  her,  and  becomes,  if  she  has 
used  her  opportunities  well,  a  more  important  factor  in  society. 

Woe,  then,  to  the  woman  whose  life  has  been  spent  in  mere  pleasure  seek- 
ing, who  has  neglected  the  cultivation  of  mind  and  heart,  and  who  knows  noth- 
ing of  the  peace  and  poise  found  in  the  comforting  assurance  of  a  Christian 
faith.  How  wearisome  the  life  of  such  a  one  becomes,  when,  possessed  only  of 
overripe  personal  charms,  she  no  longer  attracts  as  a  belle,  is  unable  to  acquire 


88  NOKMAL  me:xstkuation  and  the  menopause. 

new  interests,  and,  casting  about  for  a  new  anchorage  and  finding  none,  simply 
drifts  on  into  an  unhappy,  retrospective  old  age. 

With  too  many  of  our  poorer  class  the  change  of  life  after  years  of  hard 
labor  is  but  the  narrow  antechamber  leading  into  decrepit  age.  How  often  is 
the  physician,  who  is  himself  hale  and  hearty  in  the  forties  or  early  fifties, 
startled  when  he  discovers  some  such  broken-down  old  woman  to  be  several 
years  his  junior.  This  is  the  fault  of  our  present  world  spirit,  which  holds 
nothing  so  cheap  and  negligible  as  human  health  and  human  lives. 

According  as  the  menopause  is  well  and  safely  passed  will  tlie  woman  be 
a^Dt  to  enjoy  good  or  ill  health  throughout  this  remaining  period  of  her  life; 
a  period  of  life,  therefore,  rightly  called  ''  critical." 

The  term  "  menopause,"  strictly  speaking,  applies  to  the  complete  cessation 
of  and  the  last  menstrual  periods ;  but,  as  commonly  and  conveniently  used,  it 
covers  a  longer  period,  including  the  first  irregularities  of  menstruation  which 
mark  the  beginning  of  the  end,  as  well  as  all  the  subsequent  periods  up  to  the 
last  one,  together  with  the  subsequent  settling-down  period,  reestablishing  the 
health  on  a  new  basis.  The  period  of  irregular  menstruation  is  often  desig- 
nated by  women  as  "  the  dodging  time." 

The  menopause  thus  constitutes  one  of  the  most  striking  differences  between 
the  sexes.  Puberty  is  common  to  both,  but  in  man  the  procreative  power  then 
received  is  carried  forward  into  old  age  and  then  declines  by  imperceptible  de- 
grees, while  in  woman  it  ceases  in  middle  age.  For  every  woman  there  looms 
upon  her  mental  horizon  as  she  approaches  the  forties  this  pending  crisis  through 
which  she  must  pass,  associated  by  tradition  in  the  minds  of  many  with  a  fear 
that  when  the  change  supervenes  the  bloom  of  life  will  be  worn  off  and  the 
burdens  of  age  assumed.  Such  a  prevalent  yet  utterly  false  view  was  voiced  by 
the  French  lady  who  sadly  referred  to  her  more  youthful  attractions  in  the 
w^ords,  "  When  I  was  a  woman."  This  is  true,  if  a  woman  reaches  maturity 
impressed  with  the  notion  that  her  horizon  in  life  is  limited  by  her  reciprocal 
relations  to  the  opposite  sex  and  by  her  reproductive  activity,  that  after  the 
cessation  of  this  function  there  will  remain  but  little  of  interest  for  her  during 
the  remaining  twenty  or  twenty-five  years  (over  thirty -three  per  cent  of  her 
mundane  existence)  other  than  to  train  her  daughters  to  occupy  a  similar  field  of 
procreative  activity.  This  is  the  view  of  life  taken  by  two  hundred  millions  of 
the  Mohammedan  world.  (See  John  Foster  Fraser's  "  The  Land  of  Veiled 
Women.")  There  is,  however,  a  larger  and  truer  view,  which  it  is  our  special 
duty  as  physicians  to  inculcate  as  we  superintend  the  physical  and  mental  cul- 
ture of  our  wards,  and  that  is  the  conviction  that  life  is  but  a  school  in  the 
vestibule  of  eternity  leading  to  larger  spheres  of  activity,  responsibility,  and 
enjoyment,  and  that  each  age  is  equally  important,  and  each  brings  with  it  its 
own  peculiar  opportunities  for  spiritual  development  and  achievement.  Child- 
hood is  the  age  of  acquisitiveness  and  sharp  discipline,  with  untainted  joys 
shared  at  no  later  period.  Early  maturity  opens  up  vistas  of  duties  and  new 
and  happy  relationships,  almost  a  miraculous  revelation  of  the  possibilities  of 


MENOPAUSE. 


89 


happy  fellowship  and  service.  Later,  maturity  merging  insensibly,  as  it  ought, 
into  old  age  and  then  into  the  more  abundant,  untrammeled  life  beyond,  places 
the  crown  of  experience  and  authority  upon  a  worthy  head.  It  can  truly  be 
said  to-day  that  many  of  our  noblest  citizens,  most  devoted  to  the  common 
welfare,  are  women  at  this  time  of  life.  Woe  to  the  nation  that  misses  from 
its  midst  little  groups  of  devoted,  unselfish  women  such  as  we  know  to-day  in 
all  our  larger  cities.  W.  L.  Burrage  speaks  of  the  change  wrought  by  the 
menopause  as  "  a  period  of  rejuvenescence,"  and  quotes  the  ancients,  who  de- 
clared that  "  the  gauge  of  age  is  not  years,  but  vital  force." 


THE    NORMAL  MENOPAUSE. 

The  normal  menopause,  the  final  stoppage  of  menstruation,  is  contempo- 
raneous with  the  cessation  of  ovulation,  and  takes  place  in  an  average  of  1,082 
cases  at,  forty-five  years  and  nine  months  (Tilt).  Schaeffer,  of  Berlin  (see 
table  following  from  Veit's  Handhuch),  found  in  a  series  of  903  cases  that  the 
average  age  was  47.26  years.  Satisfactory  statistics  for  women  in  hot  coun- 
tries are  wanting. 

THE   MENOPAUSE   CAME  AT  THE  AGE   OF 


28    years  in   1 

30-34   ' 

"   4 

35 

"   2 

36 

"   3 

37 

"   2 

38 

u       7 

39 

"  14 

40 

"  24 

41 

"  15 

42 

"  52 

43 

''  46 

44 

"  48 

45 

"  87 

46 

"  58 

47 

"  78 

48 

"  90 

49 

"  86 

50 

"  100 

51 

"  54 

52 

"  58 

53 

"  42 

54 

u       yj 

55 

"   9 

56 

"   3 

57 

Total 

o 

CO     CO 

case 
cases 


'Before  40  years  in  33  cases,  or         3.65%^ 


-Of  40-44%  years  in  185  cases,  or  20.50% 


'Of  45-49 M  years  in  399  cases,  or  44.19% 


>0f  50-54%  years  in  271  cases,  or  30.01% 


'Of  55-57%  years  in     15  cases,  or     1.64% 


99.99% 


Average  age  of  menopause  in  903  cases  =  47.26  years. 


Schiilein,  of  Berlin,  had  a  case  (quoted  by  Schaeffer)  which  continued  to 
menstruate  regularly  until  she  was  sixty-two  years  old.      This  woman's  men- 


90  NORMAL    MENSTKUATION    AND    THE    MENOPAUSE. 

striial  life  extended  over  a  period  of  forty-seven  years  (Veit,  Hand.  d.  Gyn., 
1908,  p.  77).  The  fact  that  a  woman  has  borne  a  number  of  children  does  nut 
bring  on  the  menopause  at  an  earlier  date. 

The  general  average  duration  of  menstruation  is  30.52  years.  It  is  always 
important  in  estimating  the  probable  age  of  cessation  to  inquire  as  to  family 
history,  the  daughter  in  this  often  following  the  type  of  the  mother.  Burrage 
("  Gynecological  Diagnosis,"  p.  597)  gives  the  following  table  of  ages  at  which 
the  menopause  occurred  in  1,291  cases  taken  from  the  older  writers,  who  de- 
voted a  closer  attention  to  this  subject : 


Between  the  Years 

No.  of  cases. 

Percentage  of  all  cases. 

36-40  .* 

272 
595 
940 
334 
150 

11.87 

41-45 

25.97 

46-50       

41.03 

51-55                               

14.58 

Before  35  and  after  55 

6.54 

I  myself  think  that  the  nearly  twelve  per  cent  between  thirty-six  and  forty 
would  to-day  bear  closer  inspection  and  criticism,  as  the  occurrence  of  a  physio- 
logical menopause  before  forty  is  rare. 

I  know  personally  of  one  case  in  which  the  change  of  life  occurred  in  a 
married  multiparous  woman  with  all  the  customary  associated  symptoms  at 
twenty-six  years  of  age.  She  is  now  over  forty-five  and  has  been  in  perfect 
health  in  the  intervening  years. 

The  cessation  of  menstruation  took  place  suddenly  in  137  out  of  500  cases, 
Avhile  the  .average  duration  of  the  diminishing  flow  in  265  cases  was  2.2  years 
(Tilt,  "  The  Change  of  Life,"  p.  18). 

Symptoms  and  Diagnosis. — The  only  w-ell-defined  anatomical  changes  which 
take  place  at  the  menopause  are  found  in  the  ovaries,  which  are  smaller  and 
harder  and  contain  no  ripening  follicles.  The  uterus  becomes  somewhat 
smaller  and  firmer  and  the  Eallopian  tubes  gTadually  atrophy,  but  these  changes 
are  only  initial  at  the  menopause  and  aje  completed  and  most  marked  in  old 
age.  Outside  of  the  ovaries,  the  next  important  change  is  in  the  increase  of 
adipose  tissue  in  the  body,  especially  in  and  about  the  abdomen;  gradually, 
also,  in  some  women  there  are  found  coarse,  scattered  hairs  about  the  body, 
especially  on  the  face.  It  is  probably  owing  to  this  fact  that  most  women  have 
the  impression  that  with  the  menopause  there  is  a  loss  of  femininity. 

The  normal  menopause  gives  rise  to  but  slight  disturbances  and  calls  for 
no  active  treatment.  The  physician  may  recommend  to  those  in  position  to  act 
upon  his  advice  more  rest  and  greater  freedom  from  household  cares  and  re- 
sponsibilities, with  regular  hours  of  rest  and  careful  regulation  of  the  bowels. 

The  menopause  is  not  a  state  of  disease  or  unstable  health,  but  is,  like 
puberty,  simply  a  critical  period — a  time  of  instability  in  which  the  woman 
passes  out  of  one  type  and  regimen  of  life  into  another.  So  far  is  the  meno- 
pause per  se  from  being  a  malady  that  it  may,  and  often  does,  liberate  the 


MENOPAUSE.  91 

patient  from  the  sufferings  and  discomforts  of  many  years,  wiping  out,  as  with 
a  sponge,  the  pains,  the  hemorrhages,  and  the  nervousness  of  three  decades' 
duration.  To  such  a  one  the  change  is  a  manifest  blessing,  and  she  first  begins 
to  live  after  the  menstruations  have  ceased. 

The  physician  must  be  loath  to  make  a  diagnosis  of  menopause  in  a  woman 
under  forty,  although  patients  will  often  consult  him  under  the  impression  that 
they  are  changing.  By  consulting  Schaeffer's  table  it  will  be  seen  that  only  3.65 
per  cent  change  before  forty  years  of  age. 

Such  a  diagnosis  must  never  be  made  merely  because  menstruation  has  be- 
come irregular  and  scanty  for  a  few  periods.  When,  however,  such  irregularity 
persists  for  many  months,  and  there  are  concomitant  flushes  and  nervousness, 
associated  with  diminution  or  cessation,  the  presumptive  diagnosis,  in  the  absence 
of  any  discoverable  local  lesion,  is  change  of  life.  Pregnancy  must  always  be 
borne  in  mind  and  excluded.  It  must  always  be  distinguished  from  simple 
amenorrhea  in  a  woman  who  has  been  exposed  to  cold  and  whose  menstrua- 
tion is  checked  for  several  periods.  In  such  cases  there  is  generally  marked 
malaise  and  periodic  headaches  with  other  symptoms  of  a  menstrual  nisus. 
Again,  women  in  the  late  twenties  or  early  thirties  will  sometimes  take  on  an 
excessive  amount  of  fat  and  cease  menstruating.  A  pathological  menopause 
may  be  suddenly  brought  on  by  the  superinvolution  of  the  uterus  following  a 
difficult  labor  with  severe  infection.  In  such  cases  the  examination  shows  that 
the  uterus  is  small  and  atrophic  and  destined  henceforth  to  remain  inactive. 
The  menopause  may  also  be  brought  on  prematurely  by  a  too  radical  curettage 
with  a  sharp  instrument,  removing  all  or  nearly  all  the  uterine  mucosa.  This 
unfortunate  accident  has  happened  with  a  number  of  good  gynecolpgists.  A 
shock  or  great  grief  may  bring  on  the  menopause  in  the  late  thirties  or  early 
forties  suddenly  and  completely. 

Occasionally  one  notices  a  periodical  hemorrhage  from  the  hemorrhoidal 
vessels,  which  acts  as  a  safety  valve  in  place  of  the  menstrual  discharge. 

Pregnancy  During  the  Menopause. — Pregnancy  may  occur  at  any  period  of 
life  in  which  a  woman  menstruates  regularly.  It  may  also  occur  rarely  during 
the  irregular  menstruations  of  the  change,  and  even  after  the  change  has  taken 
place !  Several  authors  have  investigated  the  question  of  the  possibility  of 
pregnancy  in  the  late  forties,  the  fifties,  and  even  at  sixty  years  of  age  and  over. 
An  investigation  by  English  authors  was  stimulated  by  the  interest  felt  in  the 
celebrated  case  of  Joanna  Southcote,  who  at  the  age  of  sixty-four  was  pro- 
nounced pregnant  by  a  committee  of  medical  men !  The  diagnosis  was  made 
without  a  digital  examination,  and  the  event  proved  that  the  gentlemen  were 
mistaken.  Our  own  Fordyce  Barker,  after  an  investigation  of  all  the  extraordi- 
nary published  cases,  came  to  the  conclusion  that  but  few  of  the  recorded  late 
preg-nancies  were  well  established,  and  only  found  one  he  considered  perfectly 
trustworthy,  she  was  fifty-five  years  old. 

Tilt  says  that  he  knows  of  three  instances  in  which  conception  occurred  dur- 
ing the  change  of  life.     One  of  them  was  single  and  forty-seven  years  of  age ; 


92 


NORMAL    MENSTKUATlOiSr    AND    THE    MENOrAUSE. 


lie  quotes  another  of  a  Avoman  of  forty-seven  who  was  delivered  of  her  tenth 
child  eighteen  months  after  the  cessation  of  the  menstrual  flow.  A  lady  who 
was  married  at  the  age  of  eighteen  bore  her  first  child  at  forty-eight;  another, 
quoted  by  the  same  author,  married  at  nineteen  and  bore  her  first  child  at  fifty. 
These  cases,  of  course,  have  a  medico-legal  value  when  the  distribution  of  prop- 
erty depends  upon  the  possible  birth  of  an  heir.  He  only  found  one  case  where 
a  woman  who  had  reached  fifty-five  had  given  birth.  Pie  gives  the  following 
data  from  the  British  Birth  Register: 


Ages   of   mothers   when   their 
children  were  born 

Under 
20 

8,301 

20-25 

70,924 

25-30 

121,781 

30-35 

126,808 

35-40 
98,950 

40-45 
49,660 

45-50 
7,022 

Above 
50 

167 

Total 

Children   born  from    1831   to 
1835 

483,613 

The  question  whether  or  not  a  woman  up  in  the  forties  is  pregnant  is  always 
an  important  one.  It  often  happens  that  if  she  has  been  married  a  long  time 
without  children,  or  if  late  married  and  has  strong  maternal  instincts,  she  anx- 
iously watches  for  the  cessation  of  menstruation  as  the  sure  sign  of  a  pregnancy. 
Again,  on  the  other  hand,  a  society  woman  may  dread  a  pregnancy  in  the  forties, 
when  she  has  had  no  children  for  sixteen  or  eighteen  years,  through  a  false 
sense  of  shame.  She  may  also  base  her  conviction  not  only  on  the  skipping  of 
several  periods,  but  upon  the  fact  that  the  abdomen  is  increasing  in  size,  and 
it  may  be  she  has  felt  some  motions  within  and  has  perhaps  had  some  unusual 
sensations  in  the  breasts.  These  "  fetal  movements  "  may  be  so  clearly  defined 
as  to  mislead  even  those  who  have  passed  through  several  pregiiancies.  One  of 
my  patients,  a  worthy  widow,  knowing  that  pregnancy  was  impossible,  took 
upwards  of  sixty  dollars'  worth  of  worm  medicine,  so  convinced  was  she  that  she 
harbored  a  living  tenant.  The  physician  will  suspect  that  the  case  is  not  one 
of  pregnancy  when  he  discovers  fiushings  with  perspirations  following  and  in- 
creased nervousness,  with  a  slight  menstruation,  which  the  patient  is  inclined 
to  dismiss  as  "  insignificant " ;  he  will  become  more  skeptical  when  he  finds  that 
these  symptoms  have  persisted  for  some  months  and  that  the  enlargement  of  the 
abdomen  does  not  correspond  to  the  calculated  time  of  the  pregnancy.  A  fat 
omentum  and  increased  fat  under  the  skin  of  the  abdominal  walls  may  interfere 
with  percussion  and  make  an  external  examination  by  palpation  difficult  and 
puzzling.  All  doubt  will  be  set  at  rest  when  he  makes  a  combined  vaginal  and 
abdominal  examination  and  finds  the  vagina  unchanged  and  the  cervix  hard 
and  the  uterus  small  and  empty.  In  a  puzzling,  doubtful  case,  especially  in  a 
fat  woman,  there  should  be  no  hesitation  in  urging  a  careful  examination  under 
complete  anesthesia,  then  surely  all  doubts  will  be  set  at  rest.  If  the  question- 
able pregTianey  is  reckoned  to  be  within  the  first  or  the  second  month  and  there 
is  a  reasonable  doubt,  he  can  well  afford  to  wait  and  watch  a  couple  of  months 
to  see  whether  the  corresponding  enlargement  of  the  womb  takes  place.  One  of 
the  most  important  and  distressing  reasons  for  investigating  these  self-supposed 
pregnant  women  with  extreme  care  is  that  in  many  instances  they  are  suffering 


MENOPAUSE.  93 

from  an  actual  abdominal  enlargement  due  to  a  fibroid  or  to  an  ovarian  tumor, 
and  not  to  a  growing  fetus.  It  has  happened  to  every  active  surgeon  to  meet  one 
or  more  of  these  women  about  the  change  of  life  who  have  even  gone  so  far  as 
to  make  all  the  baby  clothes  and  engage  the  nurse  for  the  expected  confinement : 
here  joy  and  eager  expectation  are  converted  into  the  tragedy  of  an  operation. 
In  one  sad  case  a  middle-aged  woman  came  to  me  with  a  complete  infant's  ward- 
robe, and  I  found  only  carcinoma  and  ascites. 

A  little  different  from  these  are  the  cases  of  pseudocyesis  or  an  illusory 
abdominal  enlargement  due  to  fat  or  a  gaseous  distention,  or  both.  A  curious 
case  in  the  hands  of  Dr.  C.  F.  Bumam  is  the  following:  A  widow,  about  forty- 
five  years  old,  of  clear  mind,  with  good  antecedents,  suddenly  conceives  the 
notion  that  she  is  pregnant;  menstruation  stopped  for  four  months  when  she 
had  a  scanty  flow.  She  was  so  insistent  that  she  suffered  great  lower  abdominal 
pain  that  the  abdomen  was  opened  and  the  uterus  suspended.  In  spite  of  all 
assurances  she  still  believed  herself  pregnant  and  milk  came  into  her  breasts. 
This  is  manifestly  a  case  for  an  expert  psychiatrist  in  conjunction  with  the 
physician. 

Menopause  following  Lactation. — Sir  James  Y.  Simpson  and  Chiari  have 
pointed  out  the  fact  that  atrophy  of  the  uterus  and  complete  cessation  of  men- 
struation sometimes  occur  after  a  normal  puerperium,  due  to  the  exhaustion  of 
a  prolonged,  excessive  lactation.  R.  Frommel,  in  investigating  3,000  cases,  dis- 
covered lactation  atrophy  of  the  uterus  in  twenty-eight — mostly  young  women 
who  were  poorly  nourished.  The  uterus  in  some  was  found  contracted  and 
small,  its  cavity  measuring  from  5  to  5^  cm.  These  were  cases  of  concentric 
atrophy.  In  others  the  cavity  was  not  shortened,  but  its  walls  were  thin  and 
relaxed — eccentric  atrophy.  The  cervix  sometimes  atrophied,  at  other  times 
remained  normal,  while  the  adnexa  were  always  small  and  atrophic.  He  found 
this  group  practically  hopeless  from  a  therapeutic  standpoint.  Thorn,  follow- 
ing up  these  observations,  demonstrated  the  astonishing  fact  that  every  nursing 
woman  who  did  not  menstruate  exhibited  a  hyperinvolution  in  some  degree,  and 
that  up  to  a  certain  point  it  is  physiological.  Upon  the  cessation  of  lactation 
and  the  resumption  of  regular  menstruation  the  uterus  resumed  its  natural  size. 
Fraenkel  found  in  10,088  patients  95  cases  of  lactation  atrophy  of  the  uterus. 
Their  average  age  was  twenty-nine  years,  the  average  number  of  preceding 
births  3-4.  The  most  marked  diminution  in  size  was  noticed  in  the  third 
month,  while  from  the  fifth  month  on  the  size  of  the  uterus  increased.  (See 
Doderlein  in  Veit's  Handbuch.) 

Minor  Ailments  in  the  Normal  Menopause. — Biliousness  is  often  noticed  among 
the  minor  ailments,  characterized  by  a  disgust  for  food,  headache,  lassitude, 
and  constipation.  Such  cases  are  helped  by  a  course  of  blue  mass  with  com- 
pound colocynth  pills,  two  grains  of  each  every  night  for  a  week,  associated 
with  the  free  drinking  of  saline  waters,  keeping  the  emunctories  active. 

For  colic  and  flatulence  with  sluggish  bowels  Tilt  recommends  one  grain  of 
the  extract  of  opium  with  two  of  the  extract  of  colocynth  in  a  pill,  two  to  be 


94  NORMAL    MENSTEUATION    AND    THE    MENOPAUSE. 

taken  the  first  iiigiit  and  one  after,  followed  by  siilpliur  as  a  laxative  in  the 
morning. 

Exaggerated  nervousness  is  best  treated  by  free  use  of  bromides  for  a  couple 
of  weeks.  Tilt  recommends  three  drams  of  the  bromide  of  soda  with  the  same 
amount  of  the  tincture  of  orange  peel  in  a  simple  elixir  sufficient  to  make  six 
ounces,  giving  a  tablespoonful  of  this  in  a  little  water  at  four  o'clock  in  the  after- 
noon and  two  tablespoonfuls  at  night.  Such  a  plan  of  treatment  is  continued 
daily  for  two  weeks,  and  then  alternate  days  for  two  or  three  weeks  more.  If 
sleep  is  difficult,  ten  grains  of  chloral  may  be  added  to  the  dose  at  night.  He 
also  strongly  recommends  six  to  twelve  grains  of  extract  of  henbane  taken  in 
two-grain  pills  in  the  course  of  a  day. 

In  the  analysis  of  500  cases  he  found  headache  in  over  208,  or  over  forty- 
one  per  cent,  and  generally  either  frontal  or  occipital.  I  have  rarely  noted  the 
sincipital  headaches  mentioned  as  characteristic  by  the  earlier  writers.  When 
the  headache  is  severe  and  throbbing,  tincture  of  aconite  may  be  given  in  con- 
siderable doses,  beginning  with  five  drops  four  times  a  day  and  increasing  to 
twenty.  The  patient  experiences  some  relief  if  the  head  is  bathed  with  Easpail's 
sedative  lotion,  compounded  as  follows : 

^   Liq.  ammon oij 

Sod,  chloridi 5ij 

Sp.  vin.  camph oiij 

Aquse  q.  s.  ad o^xxij 

M.     S.  Apply — 

and  also  from  rubbing  the  scalp  with  cold  cream  made  up  with  one  dram  of 
camphor  to  the  ounce,  or  by  bathing  in  Cologne  water  containing  as  much  cam- 
phor as  it  will  dissolve. 

When  the  patient  is  plethoric,  with  a  full  pulse,  flushed  face,  and  but  a 
scanty  flow,  relief  is  often  found  when  menstruation  comes  on  freely.  Here  the 
old-fashioned  treatment  of  bleeding  and  taking  from  six  to  twelve  ounces  from 
the  forearm  is  undoubtedly  of  benefit.  This  treatment  may  be  associated  with 
a  brisk  purge  and  cream  of  tartar  lemonade  and  hot  foot  baths,  at  the  same  time 
limiting  the  diet,  giving  light  breakfast  and  no  meat.  In  this,  as  in  all  other 
cases,  the  urine  should  be  carefully  examined. 

For  a  debilitated  and  anemic  patient  the  contrary  plan  of  treatment  must 
be  followed.  Let  there  be  rest,  good  feeding,  red  meats,  and  tonics.  A  good 
tonic  is  the  citrate  of  quinine  and  iron  in  syrup,  about  three  to  five  grains  in 
the  elixir  of  calisaya  (a  teaspoonful)  three  times  a  day.  !For  patients  greatly 
troubled  by  perspirations  saturating  their  undergarments  Tilt  has  suggested 
the  wearing  of  a  long,  thin  flannel  dress  over  the  nightgown  to  prevent  the 
too  sudden  chilling  off. 

In  excessive  nervous  manifestations  it  is  well  to  inquire  carefully  into  the 
previous  history  of  the  patient,  whether  she  had  any  unusual  nervous  attacks 
at  the  time  of  puberty  or  later,  and  also  concerning  the  family  history  and  its 


MENOPAUSE.  95 

tendencies.  When  there  is  a  marked  history  of  insanity  in  the  family,  the 
physician  will  watch  the  patient  with  unnsual  care,  not  hesitating  to  use  seda- 
tives freely  and  seeing  that  she  lives  a  quiet,  well-regulated  life  until  the  periods 
are  well  over  and  the  danger  past. 

ABNORMAL   MENOPAUSE. 

The  menopause  becomes  abnormal  when  any  of  its  customary  symptoms  are 
greatly  exaggerated,  or  when  certain  abnormal  and  pathological  conditions  arise. 
Any  unusual  symptoms  demand  the  closest  attention  and  a  prompt  and  thorough 
investigation.  It  is  at  this  time  of  life  that  certain  serious  pel- 
vic diseases  are  of tenest  found,  and  for  this  reason  the  most  care- 
ful attention  should  be  given  to  each  case  presenting  any  ab- 
normal symptoms.  While,  on  the  one  hand,  women  at  large  are  apt  to 
exaggerate  for  the  benefit  of  the  expectant  younger  women  the  minor  discom- 
forts which  they  advertise  must  of  necessity  mark  this  period ;  the  same  public 
with  a  strange  fatuity  borne  of  the  neglect  of  ages  of  experience,  greatly  under- 
estimates the  real  major  dangers,  dismissing  such  sym.ptoms  as  pain  and  serious 
floodings  with  the  assurance  "  that  is  what  you  must  expect — it  is  only  the 
change  of  life."  Many  a  precious  life  has  been  sacrificed  and  many  a  loved 
mother  has  been  called  to  leave  the  family  circle  in  the  bloom  of  womanhood, 
because  of  an  inoperable  cancer,  because  she  has  been  thus  encouraged  by  fool- 
ish friends  to  delay  reporting  the  first  abnormal  symptoms  to  a  physician,  until, 
when  finally  forced  to  seek  advice,  she  finds  it  is  too  late.  It  would  be  better 
for  womankind  if  every  married  woman  in  the  land  were  subjected  to  a  com- 
petent physical  examination  soon  after  passing  forty  years  of  age,  whether  she 
had  unusual  symptoms  or  whether  she  had  none.  Women  are  sometimes  so 
harassed  with  the  sudden  fiushes  that  they  almost  lose  control  of  themselves 
and  feel  obliged  to  open  a  window  or  to  rush  out  of  doors  to  get  fresh  air  and 
cool  off.  In  occasional  instances  the  sweats  are  so  distressing  as  to  saturate 
the  clothing.  I  give  lutein  tablets  made  of  the  dried  corpus  luteum  taken  from 
the  ovary  of  the  pig  three  times  a  day  to  relieve  these  conditions.  For  bad 
sweats  also  give  aromatic  sulphuric  acid  in  doses  of  15  drops  three  times  a  day, 
or  atropia  in  -^jj^-gT.  tablets.     I  prescribe  the  following  pills : 

I^   Atrop.  sulph gr.  -g-^-g- 

Zinci.  oxid gr.  j 

Ex.  gentian gr.  j 

M.  ft.  pil.  1.    Make  50.     Take  1  after  each  meal. 

The  fiushings  of  a  normal  menopause  rarely  ever  approach  in  severity,  fre- 
quency, or  the  duration  of  time  over  which  they  extend,  those  distressing,  burn- 
ing-up,  overpowering  rushes  of  heat  often  experienced  at  an  artificial  meno- 
pause induced  by  the  removal  of  the  ovaries. 

Headaches  may  be  severe,  and  nervousness  is  observed  in  all  grades,  from 
a  mild  emotionalism  up  to  complete  irresponsibility  and  even  insanity. 


96  K^oi^:\rAL  :\rEXSTErATTox  axd  the  :MEX0PArsE. 

In  cases  of  milder  disorders  and  somewhat  exaggerated  nervous  symptoms, 
giddiness  and  flushes,  if  the  patient's  circumstances  will  permit,  a  trip  abroad 
to  a  foreign  watering  place  may  be  of  great  value,  entailing,  as  it  does,  the  bene- 
fits of  a  change  of  society,  the  constant  stimulus  of  expectation  amid  novel  sur- 
roundings, coupled  with  freedom  from  responsibilities,  with  regular  prescribed 
exercises  and  diet. 

DISEASES   AT  THE   MENOPAUSE. 

Burrage  (id.  sitp.)  gives  an  instructive  table  of  115  of  his  patients,  with 
their  leading  symptoms  and  his  diagnosis  in  each  case.  My  own  experience  has 
also  shown  me  that  the  following  conditions  are  not  infrequently  observed,  and 
are,  therefore,  important  at  this  period: 

(1)  Cancer  of  the  body  or  cervix  of  the  uterus. 

(2)  Endometritis. 

(3)  Polyps. 

(4)  Fibroid  tumors. 

(5)  Ovarian  tumors,  multilocular,  dermoid,  and  malignant  tumors. 

(6)  Leucorrhea,  vaginal  and  cervical. 

(7)  Pruritus. 

(8)  Bearing  down,  relaxed  vaginal  outlet. 

(9)  Uterine  displacement. 

(10)  Incontinence  of  urine. 

(11)  Tumors  of  the  breast. 

(1)  Cancer. — In  the  entire  list  of  diseases  which  are  liable  to  affect  a  woman 
at  the  menopause,  cancer  of  the  body  and  of  the  neck  of  the  womb  holds  by  far 
the  most  important  place.  All  of  the  other  affections  combined,  while  individ- 
ually important,  are  of  trifling  gravity  as  compared  to  this  great  scourge  of  our 
race,  most  commonly  observed  at  this  period.  Cancer  of  the  cervix  is  oftenest 
seen  between  the  ages  of  forty-five  and  fifty,  and  cancer  of  the  body  is  manifest 
a  decade  later.      (See  T.  S.  Cullen,  "  Cancer  of  the  Uterus.") 

Wertheim's  list  of  500  cases  of  cancer  of  the  cervix  ("  Die  Erweiterte  Ab- 
dominale  Operation,"  1911)  shows  that  in  352  cases,  or  approximately  seventy 
per  cent,  the  women  were  of  forty  years  and  above,  and  198,  or  39.6,  were 
between  forty  and  fifty. 

There  is  no  other  disease  so  dreaded  and  none  so  widespread.  It  invades  all 
families,  and  it  strikes  terror  to  every  heart  when  any  of  the  symptoms  appear 
in  a  loved  relative  or  friend.  There  is  no  other  disease,  not  even  excepting 
tuberculosis,  against  which  the  entire  medical  profession  should  wage  such 
unremitting  warfare  until  it  is  rooted  out.  But,  as  yet,  we  do  not  even  know 
its  cause,  and  for  this  reason  we  are  unable  to  anticipate  and  to  prevent  its 
occurrence  by  any  care  or  foresight.  For  this  reason  we  are  limited  to  surgery 
as  our  sole  resource,  but  even  this  too  often  fails  because  the  patient  applies 
to  the  physician  when  the  growth  has  reached  a  stage  when  it  has  passed  the 


MENOPAUSE.  97 

liiiiif-s  wlieu  a  successful  radical  operation  is  practicable.  Never  can  the  sur- 
geon say  "  I  am  sure  this  disease  will  never  come  back."  As  a  rule,  the  chances 
are  against  the  patient,  and  too  often  the  operation  is  merely  palliative.  The 
whole  question  of  the  treatment  of  cancer,  therefore,  at  the  present  day  hinges 
upon  the  early  recognition  of  the  disease,  upon  finding  out  at  the  earliest  possi- 
ble moment  that  the  patient  has  it,  and  this  responsibility  rests  not  with  the 
surgeon  and  not  with  the  specialist,  but  with  the  general  practitioner. 

I  have  dwelt  at  length  upon  this  subject  in  the  chapter  on  Cancer  of  the 
Uterus  under  the  heading  "  Prophylaxis."  I  do  not  hesitate  here  to  give  added 
emphasis  to  so  vital  a  matter  by  a  brief  summarized  repetition. 

In  order  to  get  our  cases  in  the  operable  stage,  and  as  early  as  possible,  there 
are  only  two  plans  feasible : 

(a)  To  discover  the  disease  before  it  has  caused  any  symptoms  at  all.  To 
this  end  I  have  for  many  years  recommended  a  systematic  examination  of  all 
women  after  childbirth,  and  as  soon  as  the  childbearing  period  is  over. 

(&)  The  other  is  to  instruct  the  public  and  the  general  practitioner  so  care- 
fully that  every  woman  who  complains  of  the  slightest  abnormality  about  the 
pelvis — above  all,  if  it  is  of  the  nature  of  a  discharge — should  at  once  be  sub- 
jected to  a  searching  examination.  Then,  if  cancer  is  found,  or  if  it  is  sus- 
pected, she  should  reach  the  hands  of  a  surgeon  within  a  week  from  the  day  the 
lesion  is  found.  That  this  ideal  is  attainable,  the  work  done  in  Germany, 
already  cited,  has  clearly  shown.  If  the  patient  has  an  excessive  flow,  or  a 
watery  or  foul  discharge,  or  any  pelvic  pain,  she  must  at  once  seek  her  physi- 
cian, and  her  physician  must  at  once  make  a  careful  digital  and  visual  vaginal 
examination,  and  not  rest  satisfied  until  he  has  determined  the  source  of  the 
trouble,  fearful  lest  he  should  overlook  an  early  case  of  cancer.  If  the  physician 
has  not  enough  gynecological  experience  to  give  him  confidence  in  his  own  judg- 
ment, he  must  then  suspect  every  case  of  reddened,  thickened,  nodular  cervix 
with  bleeding.  Far  better  suspect  fifty  cases  where  there  is  no  cancer  than  miss 
one  case.  He  may  feel  certain  that  the  cervix  which  bleeds  readily  on  scraping 
it  with  the  finger  nail,  or  with  an  instrument,  or  one  which  has  an  irregular, 
ragged  appearance,  with  some  evidences  of  superficial  sloughing,  is  cancerous. 
If  there  is  no  obvious  cause  for  hemorrhage  such  as  I  have  just  described,  then 
the  parts  should  be  carefully  cleansed  and  a  small  curette  introduced  into  the 
cervical  canal  and  up  into  the  uterine  body  and  gently  moved  about,  to  see 
whether  or  not  it  provokes  a  free  flow,  or  brings  away  little  pieces  of  fleshy 
tissue.  All  such  cases  must  be  put  promptly  into  the  hands  of  a  specialist; 
the  physician  must  never  temporize  by  giving  douches  or  making  topical  appli- 
cations "  to  avoid  frightening  the  patient "  until  at  last  he  is  driven  to  consult 
a  specialist,  and  learns  that  while  he  has  played  with  the  case,  squandering  his 
opportunity,  the  disease  has  been  advancing.  AVhen  the  physician  is  justified  in 
feeling  greater  confidence  in  his  own  opinion  by  a  familiarity  with  gynecolog- 
ical cases,  and  is  uncertain  in  his  diagnosis,  he  may  give  an  anesthetic  or  use 
cocaine  injected  locally  into  the  cervix,  and,  excising  a  piece  of  cervical  tissue. 


98  xoR:\rAT.  mexstruatiox  axd  the  mexopause. 

put  it  at  once  into  a  five-per-cent  solution  of  formalin,  and  send  it  to  a  competent 
pathologist  for  microscopic  examination.  If  the  patient  has  a  somewhat  pro- 
longed history  of  hemorrhages,  and  the  vagina  and  the  cervix  appear  perfectly 
normal,  while  the  body  of  the  uterus  feels  enlarged,  then  it  is  best  to  put  the 
patient  under  an  anesthetic  and  curette  thoroughly,  and  remove  as  much  as 
possible  of  the  uterine  mucosa,  and  send  it  to  a  microscopist  to  detennine 
whether  it  is  cancer  of  the  body  of  the  uterus. 

(2)  Metritis. — Metritis,  or  inflammation  of  the  body  of  the  womb,  was, 
curiously  enough,  one  of  the  keystones  of  the  uterine  pathology  of  our  prede- 
cessors, taking  the  place  of  the  endometritis  of  fifteen  years  ago.  These 
conditions  are  no  longer  accepted  as  the  causes  of  hemorrhage  at  the  menopause, 
and  I  pass  them  by. 

Endometrial  Hypertrophy. — Occasionally  profuse  flow  at  the  meno- 
pause is  caused  by  a  polypoid  overgrowth  of  the  endometrium.  All  cases 
bleeding  excessively  in  this  way  should  be  placed  under  anesthesia  and  sub- 
jected to  a  thorough  curettage,  which  will  remove  the  cause  and,  as  a  rule, 
cure  the  hemorrhage.  This  hypertrophy  is  not  merely  an  endometritis,  and  I 
do  not  know  of  any  form  of  endometritis  which  is  in  any  sense  peculiar  to  this 
period  of  life. 

Sclerosis  of  the  Uterine  Vessels  with  Hemorrhages. — One  of 
the  fairly  common  causes  of  excessive,  protracted,  blanching  uterine  hemor- 
rhages is  hypertrophy  of  the  body  of  the  uterus  (subinvolution),  associated 
with  sclerosis  of  the  uterine  vessels.  A  bimanual  examination  shows  that  the 
uterus  is  considerabh'  symmetrically  enlarged.  Such  uteri  have  frequently 
been  removed  on  a  clinical  symptomatic  diagnosis  of  cancer  of  the  body  of 
the  womb.  On  cutting  through  the  thick  wall  of  the  uterus,  the  vessels  stand 
out  from  the  musculature  like  so  many  little  white  worms.  This  is  a  condition 
to  which  attention  has  been  drawn  especially  by  Pichevin,  Petit,  Bland  Sutton, 
and  A.  H.  P.  Barbour. 

The  diagnosis  of  arterio-sclerotic  disease  may  be  made  when  the  clinical 
sigTis  cited  are  present  in  a  patient  at  or  near  the  menopause  who  has  a  large 
uterus  and  suffers  from  excessive  or  protracted  hemorrhages,  without  pain, 
where  further  dilatation  and  curettage  has  sho^^^Ti  that  there  is  no  malignant 
disease  of  the  endometrium.  The  proper  treatment  for  this  condition  is  a 
complete  hysterectomy  in  a  woman  well  over  forty.  In  younger  women  a 
subtotal  operation  perpetuates  the  menstrual  function  and  spares  her  the  sequelae 
of  the  sudden  complete  change. 

(3)  Polyps. — Oftentimes  when  a  patient  has  been  bleeding  excessively,  a 
vaginal  inspection  will  reveal  the  presence  of  a  cervical  or  a  uterine  polyp. 
Such  a  discovery  is  one  of  the  most  satisfactory  in  gynecology,  as  the  hemor- 
rhages are  often  severe  and  protracted,  even  threatening  life,  while  the  means 
of  treatment  are  so  satisfactory  and  so  certain  in  cure.  Such  a  polyp  may  hang 
down  into  the  vagina,  a  soft,  red,  fleshy,  bleeding  mass  the  size  of  a  pigeon's 
egg,  attached  inside  the  cervix  by  a  long  slender  pedicle.     Pibroid  polyps,  or 


MENOPAUSE.  99 

fibroid  tumors,  extruded  from  the  body  of  the  uterus,  are  apt  to  be  large,  shaped 
like  an  orange,  with  a  broader  pedicle.  Their  delivery  from  the  uterus  is  often 
associated  with  expulsive  pains.  Such  tumors,  I  thinly,  are  best  removed  by — 
after  placing  the  patient  under  an  anesthetic  and  duly  cleansing  the  parts — 
catching  the  tumor  on  the  right  and  on  the  left  sides  and  splitting  down  through 
the  fibroid  nodule  until  it  is  divided  into  halves ;  then  each  half  is  enucleated 
sejjarately,  leaving  the  capsule,  particularly  at  its  base,  intact.  It  is  dangerous 
to  cut  directly  through  the  pedicle,  as  there  may  be  a  partial  inversion  of  the 
uterus  at  this  point. 

A  group  of  small,  raspberry-red,  mucous  polyps  is  sometimes  seen  within 
the  cervical  canal.  These  can  be  caught  with  the  forceps  and  clipped  off  or 
thoroughly  burned  out  with  a  Paquelin  cautery. 

(4)  Fibroid  Tumors. — In  a  critical  analysis  of  1,674  cases  examined  by 
Thomas  S.  Cullen  and  myself  (see  Kelly-CuUen,  "  Myomata  of  the 'Uterus  "), 
it  was  noted  that,  when  the  myomata  do  not  impinge  on  the  uterine  mucosa,  the 
menopause  will  usually  occur  at  the  normal  time ;  but  if  at  a  later  date  the 
myomata  become  submucous,  bleeding  is  likely  to  take  place.  These  tumors, 
growing  like  minute  seeds  in  the  uterus  and  reaching  an  appreciable  size  in  from 
three  to  five  or  ten  years,  often  first  come  into  prominence  toward  the  end  of 
the  child-bearing  period,  at  about  the  time  of  the  menopause. 

Fibroid  tumors  at  this  period  are  the  cause  of  hemorrhages,  of  abdominal 
enlargements,  and  a  sense  of  pressure  in  the  lower  abdomen,  as  well  as  vesical 
disturbances.  Tor  this  reason  every  patient  at  the  menopause  who  complains 
of  any  of  these  symptoms  must  be  examined  carefully  bimanually,  if  necessary, 
under  an  anesthetic;  and  the  examiner  must  bear  in  mind  the  likelihood  of 
finding  a  fibroid  tumor.  He  must  further  be  aware  that  fibroid  tumors  thus 
found  are  apt  to  defer  the  menopause  until  the  patient  is  fifty  years  or  older. 
A  patient,  therefore,  of  forty-two  to  forty-five  years  of  age,  who  is  menstruating 
excessively  and  in  whom  a  fibroid  tumor  is  found,  has  not  the  hope  of  relief 
from  her  periodical  losses  by  the  speedy  onset  of  the  menopause.  This  fact 
determines  our  course  of  action  in  these  cases,  which  must  be  aggressive; 
namely,  hysterectomy  when  the  tumors  are  provocative  of  symptoms, 

(5)  Ovarian  Tumors — Multilocular  Cysts,  Dermoids,  and  Malignant  Tumors. — 
Among  the  major  affections  liable  to  spring  into  prominence  at  the  menopause 
are  the  various  kinds  of  large  ovarian  tumors.  Although  these  tumors  com- 
monly begin  to  grow  in  the  late  thirties  or  early  forties,  they  often  do  noli 
attract  the  attention  of  the  patient  and  induce  her  to  seek  the  advice  of  a  physi- 
cian until  about  the  time  of  the  menopause.  Spencer  Wells  ("  Ovarian  and 
Uterine  Tumors,"  1882)  gives  a  list  of  1,000  ovariotomies  in  which  227  cases 
were  between  forty  and  fifty  and  235  over  fifty  years  of  age. 

The  discovery  of  an  ovarian  tumor  is  usually  purely  accidental ;  either  the 
patient  in  dressing  notices  an  unusual  hardness  in  the  lower  abdomen  which 
alarms  her ;  or,  having  suffered  from  peculiar  irregular  menstrual  discharges, 
protracted  and  intermittent,  with  or  without  a  sense  of  pressure  or  bearing 


100  NORMAL    MENSTRUATION    AND    THE    MENOPAUSE. 

clown  in  the  pelvis,  she  goes  to  the  physician,  who,  on  examination,  finds  the 
litems  more  or  less  fixed  and  a  resistant  mass  in  one  or  both  sides  of  the  pelvis. 

The  classical  multilocular  ovarian  cyst  is  recognized,  as  a  rule,  by  its  con- 
tours, being  made  up  of  one  or  two  large  cysts  together  with  a  number  of  smaller 
ones  with  slight  depressions  between  them.  The  large  cysts  are  more  or  less 
elastic  and  fluctuating. 

A  dermoid  cyst  may  float  up  in  front  of  the  intestines  if  it  is  free,  and  is 
apt  to  be  symmetrical  and  spherical  in  form ;  many  dermoids,  however,  begin 
at  once  to  form  adhesions  with  the  pelvic  viscera  and  are  bound  down  and  re- 
sistant and  hidden  under  a  mass  of  pelvic  inflammatory  disease. 

There  is  a  peculiar  kind  of  multilocular  cyst  which  is  found  at  this  time, 
malignant  in  character,  against  which  the  examiner  must  be  especially  on  his 
guard.  In  cases  of  this  sort  the  disease  is  usually  bilateral,  fills  out  both  poste- 
rior quadrants  of  the  pelvis,  and  is  attached  to  the  broad  ligaments,  the  pelvic 
floor  and  walls  of  the  uterus,  and  the  intestines  above.  The  uterus  is  fixed  anc^ 
difiicult  to  outline.  The  cyst  contents  are  thick,  more  or  less  gelatinous,  and  the 
tumor  is  filled,  especially  at  its  base,  with  sprouting  papillary  masses.  Even 
when  the  operation  is  promptly  done,  as  it  must  be  done,  the  patient  is  fortu- 
nate indeed  if  the  disease  has  not  already  spread  beyond  the  limits  of  the  ovary 
and  out  into  the  broad  ligament  and  the  tissues  of  the  pelvic  wall.  The  opera- 
tion in  such  cases  must  be  extremely  radical. 

(6)  Leucorrhea,  Vaginal  and  Cervical. — A  leucorrhea,  vaginal  and  cervical, 
is  commonly  noted  in  the  various  text-books  as  one  of  the  distressing  conditions 
of  the  menopause.  In  my  own  practice  I  have  not  been  particularly  struck 
wdth  a  leucorrhea  associated  with  the  menopause  wdiich  is  not  simply  an  in- 
heritance from  the  woman's  previous  menstrual  history.  Tilt  says  that  out  of 
260  women  in  whom  the  menstrual  function  had  ceased,  143  had  never  been 
subject  to  leucorrhea;  of  the  remaining  117: 

The  vaginal  secretion  was  increased  at  cessation  in 77  cases. 

It  was  diminished  in ; : ....  24     " 

It  remained  stationary  in 16     " 

Many  women  only  note  the  leucorrhea  after  the  cessation  of  menstruation. 
In  a  number  it  is  of  trifling  importance,  and  needs  no  treatment  unless  the  patient 
asks  for  it  for  the  sake  of  cleanliness.  In  such  simple  cases  all  that  is  necessary 
is  to  prescribe  a  menthol  douche.  I  commonly  have  this  prescription  put  up  in 
the  form  of  tablets  as  follows,  patient  dissolving  two  of  the  tablets  in  a  pint  of 
hot  water  and  using  it  when  tepid : 

^   Menthol    gT.  1 

Sodium  bicarbonate gr.  12 

Sodium  biborate    gr.  12 

Powdered  alum   gr.  6 

If  the  leucorrhea  is  troublesome,  it  is  important  to  make  a  careful  exami- 
nation and  determine  whether  it  comes  from  the  cervical  canal  or  from  the 


MENOPAUSE.  101 

vaginal  wall.  The  cervical  leucorrhea  is  usually  seen  oozing  out  of  the  cervix, 
a  tenacious,  mucopurulent  discharge.  A  vaginal  leucorrhea  is  not  thick  and 
tenacious,  but  thin,  yellowish  or  white.  When  the  leucorrhea  comes  from  the 
vagina,  the  latter  is  usually  reddened,  showing  signs  of  patchy  inflammation. 
For  the  treatment  of  these  conditions  I  would  refer  to  the  chapter  on  Leucor- 
rhea. A  marked  vaginitis  with  shrinking  of  the  vagina  belongs  rather  to  the 
diseases  of  old  age,  q.  v.,  although  sometimes  found  at  this  period  and  some- 
times even  earlier.  A  good  douche  is  a  teaspoonful  of  sulphocarbolate  of  zinc 
to   a  pint  of  water, 

(7)  Pruritus. — Itching  occasionally  troubles  patients  at  this  period,  but  I 
refer  to  this  in  another  part  of  the  book,  associating  it  more  with  the  diseases 
of  old  age.  The  first  two  steps  to  take  in  investigating  a  case  of  pruritus  at 
middle  age  is  to  discover  whether  or  not  the  patient  has  diabetes,  and  then  to 
find  out  whether  or  not  the  itching  is  caused  by  any  irritating  cervical  or  vaginal 
discharge.  In  the  latter  case  great  relief  is  often  experienced  by  the  application 
of  a  strong  solution  (ten  to  twenty  per  cent)  of  nitrate  of  silver,  followed  by 
a  boro-glyceride  pack  and  later  by  borax  douches,  a  teaspoonful  to  a  pint  of 
warm  water.  A  distressing  pruritus  ani  may  be  kept  up  by  a  slight  thin 
vaginal  discharge.  When  the  pruritus  is  not  dependent  upon  these  causes, 
much  relief  is  obtained  by  warm  hip  baths.  A  good  lotion  is  made  by  adding 
two  drams  of  powdered  acetate  of  lead  to  four  ounces  of  milk,  applying  this 
several  times  a  day,  allowing  it  to  dry  on  the  surface.  When  the  lotion  gets 
watery  it  should  be  thrown  away. 

Tilt  further  lauds  the  use  of  a  solution  of  nitrate  of  silver,  about  eight  per 
cent  or  weaker,  well  rubbed  into  all  the  recesses  of  the  membrane, 

(8)  Bearing  Down  and  Relaxed  Vaginal  Outlet. — I  have  associated  these  two 
conditions  here  under  one  caption  because  they  may  be  either  closely  related  or 
one  exist  entirely  independent  of  the  other.  It  is  not  uncommon  at  this  period 
for  patients  to  comjilain  of  a  more  or  less  distressing  bearing  down,  which 
keeps  them  conscious  of  their  pelvic  organs.  Often  the  feeling  itself  is  not  so 
troublesome,  but  the  patient  fears  lest  it  means  a  displacement  of  the  organs 
and  an  operation.  In  such  cases  a  careful  examination  should  be  made,  not 
only  with  the  patient  lying  on  her  back  when  the  examiner  seeks  to  recognize 
a  broken-down,  relaxed  vaginal  outlet,  but  with  the  patient  standing  to  see 
whether  or  not  there  is  a  tendency  of  the  uterus  to  fall  decidedly  toward 
the  vaginal  orifice  on  straining  a  little.  A  relaxed  condition  of  the  vaginal 
orifice  is  common  at  the  change  of  life  for  many  reasons:  the  patient  may 
have  had  it  for  a  number  of  years,  but  failed  to  take  any  active  steps  for 
its  relief  so  long  as  she  was  liable  to  bear  children;  again,  for  this  or  other 
reasons,  she  postpones  an  operation  until  past  the  child-bearing  period.  In 
all  these  cases  where  there  is  a  pouting,  relaxed,  broken-down  condition  of 
the  vaginal  outlet  with  uterine  displacement,  the  wiser  plan  is  to  operate 
and  bring  tlie  levator  jnuscles  together,  restoring  the  outlet  to  its  original 
integrity. 


102  NORMAL    MEK"STErATION    AKD    THE    3MEXOPAUSE. 

(9)  Uterine  Displacement. — Closely  connected  with  the  condition  just  de- 
scribed is  retroflexion  and  downward  displacement  of  the  uterus.  When  the 
uterus  is  large  and  bearing  down  on  the  pelvic  floor,  whether  in  retroflexion 
or  descensus  or  both,  it  is  a  wise  plan  to  suture  it  in  a  good  ante  position  by 
one  or  other  suitable  operation ;  when,  however,  the  uterus  is  not  abnormal  in 
size  and  the  history  shows  that  the  retrodisplacement  has  persisted  all  through 
the  menstrual  life,  and  especially  if  she  is  unmarried  or  nulliparous,  she  is  not 
likely  to  derive  any  benefit  from  the  operation  of  putting  the  uterus  into  posi- 
tion, no  matter  how  tempting  to  the  surgeon.  The  plausil)le  argument  is 
unfortunately  fallacious :  the  patient  has  for  a  long  time  suffered  from  bearing- 
down  symptoms,  the  body  of  the  uterus  is  found  tipped  back  or  retroflexed; 
what  more  natural  than  the  conclusion  that  the  correction  of  the  trouble  will 
relieve  the  discomforts.  A  careful  study  of  the  history  of  many  of  these  cases 
will  show  that,  aside  from  the  displacement  and  the  pelvic  complaints  there 
is  a  long  nervous  history  with  complaints  of  other  kinds,  and  that  the  pelvic 
trouble  is  but  part  and  parcel  of  a  constitutional  condition  which  cannot  be 
relieved  by  surgery.  If  the  displacement  is  not  associated  with  a  broken-down 
outlet,  the  sequel  of  labor,  and  if  it  is  not  associated  with  a  decided  enlargement 
of  the  uterus,  then  let  the  operator  be  careful  to  avoid  promising  relief  by  the 
mere  surgical  correction  of  the  malposition. 

(10)  Incontinence  of  Urine. — From  the  time  of  the  menopause  on,  inconti- 
nence of  the  urine  is  noticed  with  increasing  frequency.  The  patient  first 
notices  a  little  dribble,  the  escape  of  a  few  drops  on  to  her  person  upon  cough- 
ing, laughing,  or  sneezing,  or  upon  stepping  down  or  on  any  sudden  exertion. 
This  may  increase  until  she  notices  that  she  is  wet  pretty  much  all  the  time. 
At  the  same  time  the  occasional  dribblings  are  not  sufiicient  to  empty  the  blad- 
der, so  the  toilet  is  used  about  as  often  as  heretofore.  Sometimes  in  these 
cases  there  is  a  histoy  of  a  severe  confinement  and  some  similar  disturbances 
dating  from  that  event.  A  careful  examination  shows  no  urinary  affection 
and  no  evidence  of  cystitis.  At  the  most  there  is  some  gaping  of  the  vaginal 
orifice  and  dropping  of  the  anterior  wall  of  the  vagina,  with  a  downward  dis- 
placement of  the  urethra  and  the  neck  and  base  of  the  bladder.  A  systematic 
examination  shows  nothing  special  unless  it  be  in  some  cases  a  lazy  closure 
of  the  sphincter  at  the  neck  of  the  bladder. 

The  surgeon  is  strongly  tempted  to  recommend  an  operation  at  once,  lifting 
up  the  floor  of  the  vagina  "  to  support  the  floor  of  the  bladder."  This  proves 
a  failure.  He  then  suggests  resecting  the  anterior  vaginal  wall  to  support  it 
and  "  to  prevent  the  bladder  from  coming  down,"  doing  a  cystocele  operation 
and  carrying  the  denudation  out  beyond  the  neck  of  the  bladder.  This,  too, 
fails,  and  he  is  then  at  his  wits'  end.  I  find  the  cure  for  these  cases,  both  in 
the  class  of  patients  we  are  describing  and  in  those  who  are  older  (for  it  is 
largely  a  disease  of  old  age,  as  the  trouble  gTows  worse  as  the  patient  begins 
to  lose  the  padding  of  intra-j^elvic  fat)  is  the  following:  If  the  patient  is  so 
old  that  slie  seriously  objects  to  an  operation,  if  the  vaginal  outlet  is  fairly  well 


MENOPAUSE. 


103 


Fig.  51  A. — Disc  Pessary,  which  is  Often 
Suitable  in  Relieving  lis  continence 
OF  Urine. 


lifted  up  and  will  support  a  pessary,  a  good,  snug-fitting  disk  pessary,  which 
stifi^ens  out  the  vagina  and  makes  just  a  little  pressure  at  the  neck  of  the  blad- 
der, such  pressure  as  the  finger  might 
make  while  gently  pushing  the  neck  of 
the  bladder  against  the  symphysis,  will  give 
considerable  and,  occasionally,  entire  re- 
lief. It  is  worth  while  to  try  several  pes- 
saries, each  varying  a  little  in  size,  to  see 
which  one  does  its  work  best.  (See  Fig. 
51^.) 

In  the  case  of  a  younger  woman,  or  of 
an  older  woman  who  is  not  relieved  by  a 
pessary  and  wants  a  radical  cure,  I  believe 
the  best  treatment  is  to  make  an  oval  vagi- 
nal incision  under  the  neck  of  the  bladder, 
extending  down  to  but  not  through  the  ure- 
thral mucosa,  then  carefidly  dissecting  out 
on  either  side  so  as  to  undermine  the  neck  of  the  bladder.  The  sphincter  mus- 
cles are  found  and  sutured  snugly  together  with  several  buried  silk  sutures. 
The  vagina  is  then  closed  over  this  and  the  operation  completed.  Such  cases 
are  relieved  with  practically  uniform  success. 

(11)  Tumors  of  the  Breast. — According  to  Williams,  in  1903,  10,000 
women  were  suffering  from  carcinoma  of  the  breast  in  England  and  Wales. 
In  an  analysis  of  13,824  primary  neoplasms  collected  from  London  hospitals, 
covering  a  period  of  twenty-one  years,  2,422,  or  seventeen  per  cent,  were  tumors 
of  the  breast,  and  all  but  25  of  these,  or  2,397,  were  of  the  female  breast. 
Velpeau  ("Diseases  of  the  Breast,"  Syd.  Soc,  1856),  classifying  273  cases 
of  scirrhous  and  encephaloid  tumors  of  the  breast,  says  there  were  95  between 
forty  and  fifty,  and  123  over  fifty  years  of  age,  and  remarks:  "  So  that  it  is 
between  forty  and  fifty,  and  then  between  fifty  and  sixty,  that  the  female 
breast  is  incontestably  more  exposed  to  cancer,  whether  in  the  form  of  scir- 
rhus,  or  with  the  characteristics  of  encephaloid."  He  united  in  the  following 
table  281  cases  of  hypertrophy,  cysts,  small  interlobular  fibroids,  and  ade- 
noid tumors  of  the  breast,  and  found  they  were  said  to  have  originated  at  the 
following  ages : 

Up  to  30 76 

30  to  40 64 

40  to  50 80 

50  to  60 ; 19       ' 

60  to  80 31 

Age  not  noted '. 11 

281 

V.  Angerer,  of  Miinich,  has  had  306  women  with  cancer  of  the  breast^  of 
whom  116  were  between  forty  and  fifty  years  of  age. 


104  NORMAL,    MENSTRUATION    AND    THE    MENOPAUSE. 

The  average  age  of  the  beginning  of  a  carcinoma  in  women  has  been  com- 
puted by  Horner  as  51.45,  and  by  Winniwarter  as  45.3;  by  Gebele  as  50.8. 

About  forty  to  forty-six  per  cent  occur  in  the  period  following  the  meno- 
pause. 

S.  W.  Gross  gives  the  average  age  for  the  appearance  of  carcinoma  of  the 
breast  as  between  forty  and  fifty. 

r.  Martin  quotes  Gross  as  declaring  that  a  discharge  from  the  breast  in  any 
woman  over  forty  years  of  age  is  pathogiiomonic  of  cancer.  Retraction  of  the 
skin  over  a  lump  is  always  a  serious  sign. 

A  w^ell-defined  tumor  of  the  breast  at  the  time  of  the  menopause  should 
always  be  held  as  malignant  until  an  operation  proves  the  contrary.  The  safe 
plan  is  to  assume  that  every  cystic  or  non-malignant  tumor  is  likely  to  become 
maligTiant  later  on.  Occasionally,  judging  from  my  own  experience,  errors 
in  diagnosis  are  not  infrequently  made  by  the  most  expert.  I  have  noted  re- 
garding cancer  of  the  womb.  The  same  urgency  and  immediate  operation  per- 
tains also  to  tumors  of  the  breast. 


CHAPTER    IV. 

DYSMENORRHEA. 

(1)  Dysmenorrhea:  Definition,  p.   105.     Menstrual  molimena,  p.   105.     Classification,  p.  106. 

Causes  of  dysmenorrhea  when  no  pathological  lesions  can  be  found,  p.  107.  Causes  of 
dysmenorrhea  associated  with  gross  pelvic  lesions,  p.  110.  Remedies  for  temporary 
relief,  p.  113.     Remedies  for  permanent  rehef,  p.  117.     Dilatation,  p.  121. 

(2)  Membranous  dysmenorrhea,  p.  128. 

Definition. — The  name  "  dysmenorrhea  "  signifies  simply  painful  menstrua- 
tion, and  is  applied  without  discrimination  to  all  varieties  of  suffering  asso- 
ciated with  the  performance  of  the  menstrual  function.  The  fact  that  we  are 
still  in  the  dark  as  to  the  etiology  of  menstruation  is  a  serious  obstacle  to  a 
better  understanding  of  the  true  nature  of  dysmenorrhea.  As  things  stand 
at  present  the  theories  advanced  to  explain  it  and  the  practices  employed  to 
relieve  it  are  purely  empirical. 

Menstrual  Molimena. — In  any  consideration  of  dysmenorrhea  we  find  our- 
selves in  a  difiiculty  at  the  outset,  from  the  fact  that  it  is  impossible  to  say 
exactly  what  constitutes  normal  menstruation.  Theoretically,  a  woman  in  per- 
fect health  ought  to  know  no  difference  between  the  menstrual  and  intermen- 
strual periods,  but  this  state  of  things  exists  only  among  uncivilized  people. 
The  effect  of  civilization,  and  more  especially  of  the  complex  conditions  of 
our  modern  life,  has  been  to  intensify  nervous  excitability  to  such  an  extent 
that,  the  woman  who  menstruates  to-day  without  pain  or  reflex  disturbances 
of  some  kind  is  altogether  exceptional.  Entire  absence  of  suffering  is  indeed 
so  unusual  that  text-books  of  gynecology  all  devote  some  space  to  what  is  called 
"  menstrual  molimena,"  that  is  to  say,  those  local  and  general  disturbances 
which  it  is  assumed  must  habitually  attend  menstruation. 

These  disturbances  consist  of  a  certain  amount  of  pain,  situated  in  the 
pelvis  and  extending  through  the  back  and  thighs;  and  of  nervous  excita- 
bility, manifesting  itself  most  commonly  in  headache,  depression,  and  disin- 
clination to  exertion.  The  symptoms  frequently  precede  menstruation  by  a 
period  varying  from  a  few  hours  to  a  few  days ;  in  some  cases  they  are  relieved 
by  the  establishment  of  the  flow,  while  in  others  the  suffering  is  increased  by 
its  appearance.  The  nervous  symptoms,  such  as  headache,  and  reflex 
disturbances  of  various  kinds,  are  sometimes  more  marked  than  the 
local  suffering.  The  condition  described  may  be  considered  as  constituting 
normal  menstruation;  any  marked  increase  upon  the  symptoms  being  patho- 
logical and  coming  under  the  head  of  dysmenorrhea. 

105 


106  DYSMENORRHEA. 

The  constancy  with  which  menstrual  molimena  occur  has  been  investigated 
by  Marie  Tobler  (Monatsschr.  f.  Gel.  u.  Gyn.,  1905,  vol.  22,  p.  1),  who 
interrogated  one  thousand  and  twenty  women  with  this  point  in  view.  She 
found  that  twenty-six  per  cent  had  local  pain  and  both  physical  and  mental 
disturbance,  the  term  physical  disturbance  being  used  to  indicate  such  consti- 
tutional phenomena  as  a  sense  of  general  discomfort,  of  malaise,  or  of  weak- 
ness. Four  and  four-tenths  per  cent  had  only  local  suffering.  Fourteen  per 
cent  had  local  and  physical,  but  no  mental  disturbance;  eleven  per  cent  had 
physical  and  mental,  but  no  local  disturbance ;  six  and  nine-tenths  had  physical, 
but  no  local  or  mental  disturbance.  Seven  and  eight-tenths  had  mental  dis- 
turbance only;  five  and  six-tenths  had  mental  and  local,  but  no  physical  dis- 
turbance ;  while  sixteen  per  cent  were  free  from  disturbance  of  any  kind.  In 
three  and  three-tenths  per  cent  the  patients  felt  better  than  at  any  other  time ; 
while  in  three  and  six-tenths  per  cent  they  felt  better  during  the  period,  but 
were  more  or  less  disturbed  just  before  or  after  it. 

The  reflex  symptoms  accompanying  menstruation  are  extremely  varied.  In 
addition  to  headache,  which  is  so  common  as  to  call  for  no  comment,  pains 
in  the  joints  are  often  present,  even  in  cases  where  no  rheumatic  or  gouty 
tendency  exists.  Eye  strain  is  quite  common,  with  marked  contraction 
of  the  field  of  vision  in  some  cases,  especially  when  there  is  a  tendency 
to  exophthalmic  goitre.  Skin  eruptions,  such  as  eczema  and  acne, 
make  their  appearance  or  are  increased  in  virulence.  Suffering  of  any  kind 
to  which  the  patient  is  subject,  either  temporaril}^  or  permanently,  is  apt  to 
recur  or  to  be  exacerbated  with  the  occurrence  of  menstruation;  for  instance, 
neuralgia  in  any  part  of  the  body  is  more  likely  to  attack  its  victim  at  that 
time,  and  even  so  common  a  malady  as   toothache    is  influenced  by  it. 

Classification. — From  the  standpoint  of  the  subjective  symptoms,  dysmenor- 
rhea may  be  divided  into  two  classes,  one,  in  which  the  character  of  the  men- 
strual discomfort  is  identical  with  that  which  we  have  just  defined  as  normal, 
but  is  much  more  severe;  another  in  Avhich  the  suffering  is  not  only  more 
severe,  but  of  a  different  character  from  that  just  described. 

In  the  class  characterized  by  increase  of  the  usual  suffering,  the  pelvic 
pain  begins  from  one  to  two  days  to  a  week  before  the  appear- 
ance of  the  flow.  It  is  of  a  dull,  dragging  character,  extending  all  through 
the  back  and  down  the  thighs,  and  is  often  accompanied  by  severe  headache, 
occasionally  associated  with  nausea,  extreme  lassitude,  and  nervous  excitability. 
In  some  cases  the  symptoms  are  greatly  relieved  by  the  establishment  of  men- 
struation ;  in  others  they  continue  throughout  its  duration. 

In  the  second  class  of  cases,  the  pain  begins  just  before,  or  exactly 
with  the  appearance  of  menstruation.  It  is  sharp,  well-defined,  and 
cramp-like  in  character,  coming  on  in  paroxysms  whicli  last  a  minute  or  two 
and  recur  at  short  intervals.  This  form  of  dysmenorrhea  is  less  often  accom- 
panied by  reflex  disturbances  than  the  other. 

There  is  still  another  variety  of  dysmenorrhea  in  which    both    types    of 


CAUSES    OF    DYSMENOKEHEA.  107 

pain    are    present,    the  spasmodic  form  being  superadded  to  the  dull  per- 
sistent pain  and  the  two  being  present  in  varying  proportion. 

I  shall  refer  again  to  these  two  types  of  dysmenorrhea  in  the  discussion 
of  its  treatment;  at  present  I  will  proceed  at  once  to  consider  the  various 
theories  as  to  its  causation. 


CAUSES    OF    DYSMENORRHEA    WHERE    NO    PATHOLOGICAL 
LESIONS    CAN    BE    FOUND. 

It  has  long  been  recognized  that  dysmenorrhea  is  not  necessarily  associated 
with  a  demonstrable  abnormal  condition  of  the  reproductive  organs.  On  the 
contrary,  dysmenorrhea  of  the  most  severe  and  obstinate  character 
may  exist  in  the  absence  of  any  discoverable  local  disease  what- 
ever, while  some  cases  of  advanced  disease  in  the  uterus  and 
appendages  are  entirely  free  from  pain  in  menstruation.  Vari- 
ous theories  have  been  developed  to  explain  the  existence  of  dysmenorrhea  in 
the  absence  of  uterine  or  ovarian  disease,  the  most  widely  recognized  of  which 
are  the  following: 

Mechanical  Dysmenorrhea. — This  theory  presupposes  a  constriction  of 
the  uterine  canal,  by  means  of  which  the  escape  of  the  menstrual  fluid 
is  impeded.  It  was  first  advanced  by  Sir  James  Mackintosh  of  Edinburgh 
and  was  further  developed  by  Marion  Sims  and  Sir  James  Y.  Simpson.  In 
detail  it  is  based  on  the  assumption  that  an  obstacle  is  present  in  the  uterine 
canal,  and  that  in  order  to  force  the  blood  past  this  obstacle  the  uterus  con- 
tracts forcibly,  the  contraction  being  realized  subjectively  in  the  form  of 
uterine  colic  and  constituting  the  pain  known  as  dysmenorrhea.  The  obstacle 
in  question,  according  to  the  advocates  of  the  theory,  may  be :  ( 1 )  A  kink  in 
the  cervical  canal,  due  to  an  anteflexion,  or,  more  rarely,  a  retroflexion;  (2)  a 
stenosis  of  the  internal  os,  which  may  be  congenital,  or  the  result  of  spasmodic 
contraction  of  the  circular  muscle  fibres  at  the  internal  os,  or  of  premenstrual 
swelling  of  the  mucosa ;  ( 3 )  a  congenital  stenosis  of  the  external  os  or  of 
the  entire  cervical  canal;  (4)  intra-uterine  polypi  acting  as  ball  valves;  (5) 
clots  of  blood,  or  (in  membranous  dysmenorrhea)  a  membrane  forced  into  the 
internal  os. 

This  theory  affords  a  most  plausible  explanation  of  the  clinical  features 
of  many  cases  of  the  spasmodic  variety  of  dysmenorrhea,  where  the  pain  is 
sharp  and  colicky,  comes  on  shortly  before  the  flow,  and  is  associated  with 
scanty  menstruation,  becoming  more  free  as  the  pain  subsides.  It  received 
substantial  support  from  the  fact  that  dilatation  of  the  cervix,  which  was  sup- 
posed to  remove  the  obstruction  and  should,  therefore,  theoretically,  relieve  the 
23ain,  was,  clinically,  a  perfect  success  in  many  cases.  These  facts  caused  it  to 
receive  a  ready  Avelcome,  but  further  experience  and  a  closer  oxamination  of  the 
results  liave  to  a  large  extent  destroyed  confidence  in  it.  Vedeler  {Arcli.  f.  Gyn., 
1883,  vol.  21,  p.  211)  has  shown  that  out  of  a  large  number  of  women  with 


108  DTSMENOEKHEA. 

anteflexed  uteri,  the  percentage  of  those  free  from  dysmenorrhea  is  as  great 
as  of  those  who  suffer  from  it.  Duncan  has  pointed  out  that  observation  of 
the  section  of  a  uterus  in  extreme  anteflexion  shows  that  the  flow  of  blood 
along  the  flexed  canal  would  be  obstructed  only  in  a  degree  which  could  not 
practically  be  of  the  slightest  importance.  Moreover,  the  uterine  sound  has 
been  passed  repeatedly  through  the  internal  os  during  menstruation,  showing 
that  at  this  time  the  stenosis  does  not  exist.  Again,  it  is  estimated  that  the 
amount  of  menstrual  blood  lost  is  one  drop  in  three  minutes,  and  it  has  been 
demonstrated  that  menstrual  blood  flows  easily  at  this  rate  through  a  tube 
much  smaller  than  any  possible  stenosis  of  the  os,  or  of  the  canal.  It  has 
also  been  shown  that  during  the  acme  of  the  pain,  and  just  before  the' flow 
is  established,  there  is  no  blood  in  the  uterus  at  all.  In  support  of  the  theory 
it  has  been  urged  that  when  a  uterine  sound  is  passed  into  the  nulliparous 
uterus,  resistance  is  often  encountered,  but  this  does  not  necessarily  imj^ly  the 
presence  of  a  pathological  stenosis,  and  careful  examination  usually  shows  that 
the  difficulty  arises  from  the  tip  of  the  sound  being  caught  in  the  folds  of  the 
mucosa,  or  from  its  encountering  a  flexion. 

Dysmenorrhea  Associated  with  Maldevelopment  of  the  Reproductive  Organs. 
— Insufficient  development  of  the  reproductive  organs  is  often  associated  with 
painful  menstruation,  but  the  relation  between  the  two  is  not  yet  determined. 
Some  authorities  claim  that  this  form  of  dysmenorrhea  is  a  neurosis ;  others, 
that  it  arises  from  a  deficiency  in  the  calibre  of  the  blood  vessels,  which  are 
too  small  to  receive  the  increased  amount  of  blood  necessary  to  establish  the 
menstrual  hyperemia ;  others,  again,  consider  it  due  to  the  fact  that  the  uterine 
cavity  is  too  small  to  accommodate  the  swollen  endometrium ;  and  still  another 
view  claims  that  anteflexion  is  present  in  all  such  cases,  on  account  of  the 
maldevelopment  of  the  anterior  surface  of  the  uterus,  and  that  while  the 
increased  blood  pressure  tends  to  straighten  the  flexed  organ,  the  resistance 
rendered  by  the  lack  of  distensibility  of  the  uterine  parenchyma  occasions  the 
pain.  ISTone  of  these  explanations  can  be  accepted  as  satisfactory,  and  although 
there  is  no  doubt  that  maldevelopment  of  the  pelvic  organs  is  an  important 
causal  factor  in  many  cases  of  dysmenorrhea,  we  are  at  present  unable  to  say 
more  than  that  the  incompletely  developed  organ  is  not  capable  of  prompt, 
efficient  response  to  a  normal  impulse,  and  therefore  does  not  carry  out  its 
function  with  ease,  hence  the  pelvis  is  not  relieved  of  its  increased  blood 
pressure  and  there  is  a  tendency  to  stasis.  A  poor  physical  development 
is  often  associated  with  a  similar  condition  of  the  pelvic  organs,  but  mal- 
development of  the  uterus  and  adnexa  is  not  necessarily  associated  with  gen- 
eral defective  development.  Women  in  robust  health,  whose  only  ailment  is 
dysmenorrhea,  sometimes  present  imperfectly  formed  uteri  and  ovaries  of  the 
puerile  type. 

Neurotic  Dysmenorrhea. — In  some  instances,  dysmenorrhea  is  undoubtedly 
a  pure  neurosis,  explicable  as  a  hyperesthesia  of  the  endometrium;  in 
other  words,  it  is  an  abnormal  perception  of  the  uterine  contractions  physio- 


CAUSES    OF    DYSMENOEEHEA.  109 

logically  present  at  every  menstrual  period,  but  not  usually  appreciable,  it 
being  supposed  that  uterine  colic  is  analogous  to  intestinal  colic  and  due  to  a 
tetanic  spasm  of  the  circular  fibres  at  the  internal  os.  The  pain  may  be  due 
also  to  a  physiological  difficulty  occasioned  by  the  breaking  down  of  the  mucous 
membrane  of  the  capillaries  which  induces  a  sort  of  pelvic  headache.  In 
dysmenorrhea  of  this  type  the  patients  are  not  anemic,  their  functions  are  well 
performed,  and  examination  shows  their  reproductive  organs  normally  devel- 
oped, so  that  the  dysmenorrhea  must  be  considered  as  a  pure  neurosis  whose 
exact  nature  cannot  be  clearly  defined.  It  frequently  happens  that  dysmenor- 
rhea will  make  its  appearance  during  neurasthenia  in  women  who  have  never 
suffered  from  it  before.  In  such  cases  it  is  often  a  nice  question  how  much 
the  dysmenorrhea  is  the  result  of  the  neurasthenia  and  how  much  it  is  occa- 
sioned by  local  disturbance  of  the  organs. 

Nasal  Dysmenorrhea. — In  1897  Tleiss  advanced  a  theory  of  dysmenorrhea 
based  on  the  fact  that  certain  cases  could  be  relieved  by  the  application  of  a 
twenty  per  cent  solution  of  cocain  to  the  so-called  "  sexual  spots  "  in  the  nasal 
mucous  membrane,  urging  in  support  of  his  theory  that  at  the  time  of  men- 
struation these  spots  increase  in  size  and  consistency,  become  cyanotic,  and 
bleed  easily.  The  theory  found  some  supporters,  amongst  them  J.  Mackenzie, 
but  it  has  never  met  with  general  acceptance.  A  most  sensible  paper  on  the 
subject  by  G.  Kolischer  (Amer.  Jour.  Obst.,  1904,  vol.  49,  p.  804),  ascribes 
the  good  results  observed  in  certain  hysterical  patients  to  the  effects  of  sugges- 
tion, and  points  out  that  cocainization  of  other  mucous  surfaces  produces  the 
same  effect.  For  instance,  in  two  cases  where  relief  was  promptly  experienced 
after  the  application  of  cocain  to  the  "  sexual  spots,"  the  same  benefit  was 
obtained  at  the  next  menstrual  period  from  the  application  of  cocain  else- 
where, in  one  case  to  an  erosion  of  the  cervix,  and  in  the  other  to  a  previously 
cleansed  rectum. 

Dysmenorrhea  from  General  111  Health. —  There  is  still  another  variety  of 
dysmenorrhea,  common  in  young  girls  in  whom  the  menstrual  habit  is  becom- 
ing established,  and  usually  associated  with  a  variety  of  dyscrasias,  the  most 
prominent  of  which  are  anemia  and  chlorosis.  This  form  does  not 
usually  persist  beyond  the  twentieth  year,  although  it  is  occasionally  met  with 
in  young  married  women.  Many  of  these  patients  live  among  poor  hygienic 
surroundings  which  keep  their  physical  vigor  below  par ;  others,  on  the  con- 
trary, are  found  among  the  higher  classes  who  live  amidst  luxurious  condi- 
tions, but  are  victims  to  the  overstrain  caused  by  the  perpetual  rush  and 
excitement  of  constant  social  engagements,  or  the  present  efforts  towards  the 
higher  education  of  women. 

These  are  the  principal  theories  concerning  the  etiology  of  dysmenorrhea 
not  associated  with  gross  pathological  lesions  of  the  reproductive  organs. 
Other  explanations  less  well  recognized  are  to  be  noted  also.  Chronic  endo- 
metritis, causing  pain  in  menstruation  through  hyperesthesia  of  the  endo- 
metrium is  sometimes  spoken  of,  and  also    chronic    ovaritis;    but  neither 


110  BYSMENORIIHEA. 

of  these  causes  has  jet  been  demonstrated.  In  sixty-four  cases  of  dysmenor- 
rhea without  abnormalities  of  the  pelvic  organs,  which  were  treated  in  my 
clinic  by  dilatation  and  curettage,  chronic  endometritis  Avas  found  on  micro- 
scopical examination  in  only  four  cases,  and  in  no  one  of  the  four  was  it  well 
marked.  A  form  of  painful  menstruation,  known  as  ovarian  dysmenor- 
rhea, is  sometimes  spoken  of,  in  which  there  is  extreme  tenderness  of  the 
ovary  during  the  period,  demonstrated  by  pressure  upon  it,  and  explained 
by  thickening  of  the  ovarian  capsule  preventing  the  expansion  of  the  ovary 
during  the  period  of  congestion;  it  has  never  come  under'  my  observation. 
Perimetritis  and  salpingitis  are  sometimes  the  cause  of  pain  in  men- 
struation on  account  of  the  peritoneal  pain  occasioned  by  contractions  of  the 
tubes  and  uterus.  Some  writers  recognize  another  form  of  dysmenorrhea 
known  as  "neuralgic  "  which  is  classed  with  the  pure  neuroses  as  analogous 
to  intercostal  or  facial  neuralgia.  Dysmenorrhea  is  sometimes  met  with  in 
women  of  a  gouty  or  rheumatic  constitution  as  a  manifestation  of  the 
diathesis;  its  association  with  the  dyscrasia  being  demonstrated  by  the  entire 
relief  afforded  from  remedies  appropriate  to  its  alleviation.  In  dysmenorrhea, 
not  otherwise  explicable,  occurring  in  women  with  a  rheumatic  or  gouty  his- 
tory, it  should  always  be  borne  in  mind  as  a  possible  cause,  even  if  there  are 
no  other  manifestations  of  the  diathesis. 


CAUSES  OF  DYSMENORRHEA  ASSOCIATED  WITH  GROSS  PATHOLOGICAL 

LESIONS. 

While  there  are  many  cases  in  which  a  most  severe  dysmenorrhea  is  present 
without  the  slightest  local  lesion  or  displacement,  there  are  also  a  considerable 
number  where  it  exists  in  the  presence  of  some  pathological  condition,  of 
greater  or  less  significance,  by  which,  there  can  be  no  doubt,  it  is  sometimes 
induced.  In  order  to  investigate  this  matter,  I  inquired  into  the  histories  of 
one  thousand  patients  admitted  consecutively  into  the  Johns  Hopkins  Hos- 
pital, and  found  that  two  hundred  and  twenty-nine  of  them  suffered  from 
dysmenorrhea  which  was  apparently  the  result  of  a  definite  pelvic  lesion.  The 
abnormal  conditions  which  may  occasion  dysmenorrhea  are  many  and  various, 
but  the  three  most  frequently  met  with  are:  (1)  backward  displacement 
of  the  uterus  ;  (2)  pelvic  inflammatory  disease  ;  (3)  myoma. 
Of  the  cases  spoken  of,  forty-one  per  cent  were  associated  with  retrodisplace- 
ments  of  the  uterus ;  thirty-seven  per  cent  with  pelvic  inflammatory  disease ; 
and  eleven  per  cent  with  myomata.  The  remaining  eleven  per  cent  were  dis- 
tributed among  various  minor  conditions. 

Retroposition  of  the  Uterus. — Dysmenorrhea  is  more  commonly  associated 
with  retroposition  of  the  uterus  than  with  any  other  abnormal  condition  of 
the  pelvic  organs.  An  analysis  of  a  number  of  cases  of  backward  displace- 
ments, treated  at  the  Johns  Hopkins  Hospital,  made  by  my  former  associate. 
Dr.  G.  R.  Holden,  showed  that  out  of  one  hundred  and  twenty  nulliparae,  one 


CAUSES    OP   DYSMENOERHEA.  Ill 

hundred  and  nine,  or  ninety  per  cent,  suffered  from  dysmenorrhea  before 
operation.  In  multipara?,  backward  displacements  are  not  so  frequently  asso- 
ciated with  dysmenorrhea,  there  being  one  hundred  and  thirteen  cases  of  it 
in  two  hundred  and  two  cases  of  retroposition,  or  fifty-six  per  cent.  Dys- 
menorrhea is  occasionally  the  only  symptom  caused  by  the  displacement,  but 
more  often  it  is  only  one  of  a  series  of  manifestations,  although,  perhaps,  the 
most  severe.  There  is  no  constant  type  of  dysmenorrhea  associated  with  retro- 
position  ;  it  is  more  apt  to  continue  throughout  the  entire  period  than  the  dys- 
menorrhea of  nulliparae  without  lesion.  Gastric  symptoms,  headache,  and 
other  neurotic  manifestations  are  often  marked  features,  owing  to  the  neuras- 
thenia which  almost  invariably  accompanies  such  cases. 

Pelvic  Inflammatory  Disease. — About  one-third  of  all  the  inflammatory  con- 
ditions of  the  uterus,  tubes,  or  ovaries,  acute  or  chronic,  are  accompanied  by 
dysmenorrhea.  The  proportion  of  cases  with  menstrual  pain  is  about  the  same 
in  acute  and  chronic  affections,  and  the  intensity  of  the  suffering  bears 
no  relation  to  the  extent  of  the  pathological  process.  Cases  in 
which  the  entire  pelvic  organs  are  the  seat  of  inflammatory  disease  may  have 
no  pain  in  menstruation  whatever,  while  a  few  adhesions  binding  down  lightly 
one  tube  or  ovary,  or  both,  may  give  rise  to  severe  suffering.  Here  also  there 
is  no  constant  type  of  pain.  The  suffering  usually  comes  on  a  few  days  before 
the  flow  and  lasts  through  the  entire  period.  It  is  commonly  dull  in  character, 
and  is  often  referred  to  a  wide  area  over  the  abdomen,  back,  and  thighs.  There 
may  be  no  symptom  of  the  condition  except  dysmenorrhea. 

Myomata. — During  the  year  190 Y  the  histories  of  two  hundred  cases  of 
myoma  in  women  under  forty-five  were  examined  at  the  Johns  Hopkins  Hos- 
pital to  ascertain  what  percentage  of  their  number  suffered  from  dysmenorrhea. 
Ninety-four  of  the  cases  were  white  and  one  hundred  and  six  black.  Only 
those  cases  were  considered  positive  which  "  showed  the  onset  of  dysmenorrhea 
with  the  present  illness."  Of  these  two  hundred  cases  of  uncomplicated  myoma 
(adeno-myoma  not  included),  twenty-five  per  cent  showed  that  painful  men- 
struation had  made  its  appearance  since  the  onset  of  the  trouble  for  which  the 
patient  sought  advice.  This  estimate  of  the  proportion  of  dysmenorrheas  asso- 
ciated with  myoma  may  seem  low,  but  another  set  of  investigations  carried  on 
at  the  Johns  Hopkins  a  little  earlier  gave  a  percentage  of  twenty  per  cent, 
which  is  even  lower. 

Dysmenorrhea  is  most  frequently  seen  with  submucous  and  inter- 
stitial myomata  and  is  rare  in  the  subperitoneal  form.  Here,  again, 
there  is  no  distinctive  form  of  suffering.  Severe  dysmenorrhea  is  most  often 
observed  in  the  case  of  small  tumors,  and  I  pause  here  to  call  attention  to 
the  fact  that  a  number  of  apparently  inexplicable  dysmenorrheas 
are  due  to  the  presence  of  extremely  small  myomata.  In  a  case 
which  passed  through  my  hands  not  long  since,  the  patient  had  been  suffering 
for  some  years  with  extreme  dysmenorrhea  and  more  or  less  constant  pain, 
so  that  her  general  health  was  quite  broken  down.      When  the  uterus  was 


112  DTSMENOEEHEA. 

opened  a  very  small  submucous  myoma  was  found  and  removed,  with  complete 
relief  of  the  suffering. 

TREATMENT    OF    DYSMENORRHEA. 

An  important  question  which  at  once  arises  in  almost  every  case  of  dys- 
menorrhea is  the  propriety  of  making  a  local  examination.  There  should,  of 
course,  be  no  hesitation  in  the  case  of  married  women,  or  in  cases  of  inflam- 
matory disease.  But  there  are  many  instances  of  young  women  who  suffer 
from  dysmenorrhea  pure  and  simple,  when  the  question  of  examination  must 
receive  careful  consideration.  It  is  always  best  to  exhaust  all  general  thera- 
peutic measures  before  making  it;  and,  in  a  large  number  of  cases,  if  these 
are  carried  out  conscientiously  over  a  long  period  of  time,  the  suffering  will 
be  relieved.  If,  however,  the  case  is  an  aggravated  one  when  first  seen;  if  it 
persists  in  defiance  of  all  therapeutic  measures;  if  it  cannot  remain  under 
observation ;  or,  if  the  circumstances  are  such  as  to  prevent  the  general  meas- 
ures being  consistently  carried  out,  an  examination  should  be  made  under  an 
anesthetic. 

With  this  precaution,  an  examination  can  be  made  without  injury  to  the 
hymen,  while,  should  any  simple  operation  such  as  dilatation  and  curettage 
be  indicated,  it  can  be  performed  at  the  same  time.  Such  a  course  enables  the 
physician  to  dispense  with  the  endless  local  treatments  which  are  so  objection- 
able in  young  women. 

The.  various  remedial  measures  which  experience  shows  to  be  beneficial  are 
as  follows: 

GENERAL  REMEDIAL  MEASURES. 

Attention  to  General  Health. — In  all  cases  of  dysmenorrhea  the  closest 
attention  to  general  health  is  indicated.  In  a  large  proportion  of  cases  the 
patient  will  show  more  or  less  evidence  of  malnutrition  of  some  kind  or  other, 
and  this  should  be  the  object  of  persistent  attention.  A  proper  quantity  of 
nutritious  food  is  essential,  and  if,  as  often  happens,  the  appetite  is  so  impaired 
as  to  make  it  impossible  to  consmne  this  at  ordinary  meals,  the  deficiency 
should  be  made  up  by  feeding  the  patient  in  small  amounts  at  frequent  inter- 
vals. A  glass  of  milk,  a  cup  of  beef  tea,  a  sandwich,  some  malted  milk,  or 
any  light  nutritious  food  taken  between  meals  and  just  before  going  to  bed 
will  generally  be  sufficient,  and  as  the  general  condition  improves,  the  appetite 
will  increase. 

Sleep. — A  case  of  the  kind  under  consideration  should  always  have  fully 
eight  hours'  sleep  and  more,  if  possible.  In  young  girls  who  have 
not  attained  maturity,  or  in  cases  where  the  patient  is  markedly  anemic,  there 
must  always  be  more,  either  at  night  or  in  the  day  time.  An  excellent  plan 
is  a  sleep  of  one  or  two  hours  in  the  early  afternoon.  All  late  hours  and 
excitement  should  be  avoided  with  young  girls  at  school,  and  the  greatest  care 
should  be  exercised  to  prevent  over-exertion.     The  requirements  of  our  large 


TREATMENT  OF  DYSMENOKRHEA,  113 

schools  are  such  as  to  tax  the  caiDacities  of  a  growing  girl  to  the  utmost,  and 
if  she  is  to  keep  up  to  them  she  must  have  every  external  aid  in  the  healthy- 
regulations  of  her  life  out  of  school  hours.  A  young  girl  suffering  from  dys- 
menorrhea should  never  be  sent  to  school  during  the  menstrual  period ;  and 
in  a  good  many  cases  she  should  be  taken  away  altogether  for  some  months, 
or  a  year,  if  necessary. 

Fresh  Air  and  Exercise. — A  considerable  amount  of  time  spent  in  the  open 
air  is  of  vital  importance.  The  conditions  of  a  woman's  life  in  this  respect 
are  greatly  improved  upon  what  they  were  a  generation  ago,  and  a  variety  of 
outdoor  amusements  are  now  open  to  her.  Walking,  riding,  driving, 
bicycling,  or  some  form  of  active  game,  such  as  tennis,  golf,  or 
basket  ball,  are  very  desirable ;  and  some  hours  spent  out  of  doors, 
in  all  but  the  most  inclement  weather,  should  form  part  of  the 
routine    of   each    day. 

Rest. — More  benefit  is  derived  from  rest  in  the  treatment  of  dysmenorrhea 
than  from  any  one  other  remedy.  Absolute  rest  in  bed  during  the 
periods  is  essential.  Every  patient  suffering  from  established  dys- 
menorrhea should  remain  in  bed  for  two  to  three  days  at  each  menstruation, 
and  whenever  it  is  possible,  the  rest  should  begin  before  the  appearance  of  the 
flow.  Careful  observance  of  this  rule  in  conjunction  with  other  remedies  will, 
in  many  cases,  completely  relieve  the  dysmenorrhea,  and  the  patient  will  be 
able  after  some  months  to  resume  ordinary  habits  during  menstruation.  In 
other  cases  it  will  be  necessary  to  continue  the  practice  of  rest  in  bed  for  at 
least  the  first  twenty-four  hours  each  time,  if  the  relief  from  suffering  is  to 
be  permanent. 

Regulation  of  the  Bowels. — Dysmenorrhea  is  frequently  associated  with 
constipation,  so  frequently,  indeed,  that  keeping  the  bowels  open,  and  even 
a  little  relaxed  at  the  time  of  the  menstrual  period,  is  often  most  effectual  in 
giving  relief.  I  have  known  one  case  in  which  perfect  relief  for  several  periods 
was  obtained  by  taking  a  heaping  teaspoonful  of  Husband's  magnesia  every 
morning  for  three  or  four  days  before  menstruation.  In  young  girls  who 
suffer  from  dysmenorrhea,  it  will  often  be  discovered  on  close  questioning 
that  there  is  no  regular  evacuation  of  the  bowels,  and  that  the  patient  is  quite 
unaware  of  the  importance  of  the  habit  to  either  her  general  health  or  her 
menstruation.  In  such  cases  it  is  well  to  focus  attention  upon  this  point  until 
the  constipation  is  overcome,  and  this  will  often  result  in  entire  relief  of  the 
menstrual  suffering. 

REMEDIES    FOR    RELIEF    OF    PAIN    DURING    MENSTRUATION. 

Opium  should  rarely  be  given  for  the  relief  of  dysmenorrhea, 
any  more  than  for  any  other  form  of  protracted  suffering  characterized  by 
paroxysms,  that  does  not  tend  to  a  fatal  issue.  The  various  forms  of  alco- 
holic stimulants  so  much  in  vogue  are  also  contraindicated. 
There  is  a  strong  tendency  among  the  poorer  classes  to  seek  relief  in  either 
9 


114  DYSMEXOREHEA. 

gin  or  wliiskev,  and  this  point  should  be  especially  borne  in  mind  among  dis- 
pensary i)atients.  The  various  patent  medicines  taken  for  the  relief  of  pain 
all  contain  a  large  percentage  of  alcohol  and  their  use  should  be  systematically 
discouraged.  The  percentage  of  alcohol  by  volume  in  some  of  these  com- 
]")0unds,  as  given  by  the  Massachusets  State  Board  Analyst,  is  as  folloTvs : 

Lydia  Pinkham's  Vegetable  Compound 20.6 

Peruna 28.5 

Paine's  Celery  Compound 21.0 

Jackson's  Golden  Seal  Tonic 19.6 

Schenk's  "  Sea-weed  Tonic,"  "  entirely  harmless  "  ! 19.5 

Ayer's  Sarsaparilla 26.2 

Hood's  Sarsaparilla    18.8 

It  is  necessary,  however,  or  at  any  rate  desirable,  to  combine  a  stimulant 
with  the  coal-tar  preparations  which  are  so  much  used  for  the  relief  of  dys- 
menorrhea, in  order  to  counteract  the  depressing  effect  upon  the  heart  exercised 
by  that  class  of  remedies.  Five  grains  of  phenacetin  with  two  teaspoonfuls  of 
whiskey  are  sometimes  given  for  the  relief  of  menstrual  pain,  but  it  should 
always  be  given  by  the  physician  in  the  form  of  a  prescription,  and  never  put 
into  the  patient's  hands  as  a  remedy  for  general  use,  which  she  is  at  liberty 
to  renew  at  her  discretion.  The  evils  of  alcoholic  stimulation  are  so  great, 
however,  that  I  prefer  to  give  twenty  to  thirty  drops  of  the  aromatic  spirits 
of  ammonia  in  a  little  water. 

The  following  formulae  for  the  relief  of  menstrual  pain  I  have  found  use- 
ful in  my  practice : 

^   Pheuac.  1  __       ' 

>  aa „  .    ffr.  n 

Salol       i  ^       •' 

M.     Pt.  charta.     ]\Iitte  tales  no.  vi. 
S.       One  powder  every  four  hours. 

3^   Potass,  bromid 3ij 

Elixir  guaran.   and  celer foij 

]M.      S.   One  dessertspoonful  every  four  hours  in  hot  water. 

I^   Acetanil.    (Phenac.)    gr.  v 

Codein gT.  ss 

M.     Pt.  charta.     Mitte  tales  no.  iv. 

S.       One  powder  and  repeat  in  an  hour. 

19  Apiol gr.  1 

Pt.  caps.  no.  xii. 

S.     One  capsule  each  night  and  morning  for  two  or  three 
days  before  menstruation. 


TREATMENT    OF    DYSMENORRHEA.  115 

I>!   Hydrastis  canacl f§ij 

S.      Twenty-five  drops  in  a  wineglassfnl  of  water  twice  a 

day,    beginning    a    week    before    menstruation    and 

continuing  through  the  flow. 

Dr.  Walter  L.  Burrage  recommends  the  various  Ilelonias  compounds, 
which  he  has  found  useful.  The  best  of  them,  in  his  opinion,  are  "  Mistura 
Helonin  Compound  "  and  the  fluid  extract  of  "  ITelonias  Compound."  These 
preparations  are  safest,  as  they  do  not  contain  an  opiate,  and  the  quantity 
of  alcohol  per  dose  is  infinitesimal.  The  compound  mixture  of  helonin,  known 
as  "  Green  Mixture,"  because  of  its  brilliant  color,  may  be  given  in  doses  of  a 
teaspoonful  in  half  a  teacupful  of  hot  water  every  fifteen  minutes  during  a 
paroxysm  of  pain,  or  three  times  a  day  during  the  intermenstrual  period,  or 
for  a  week  before  the  flow  is  expected. 

The  two  following  prescriptions  given  by  B.  C.  Hirst  ("  Diseases  of 
Women,"  2d  edition,  p.  421)  seem  likely  to  be  valuable: 


I^   Acetanil gr.   ij 

Ammonite  carb gr.  iij 

Heroin gr.  ^t 

M.     Ft.  pil.     Mitte  tales  no.  vi. 

S.       One  pill  every  hour  for  three  hours. 


^   Tinct.  opii  camph f.oj 

Tinct.   zingerb f§j 

Spts.   chlorof 3ij 

Syrup,  acac f^ss 

Aq.  menth.  pip.,  q.  s.  ad f.oiv 

M.      S.  ~  One  tablespoonful  when  required  for  cramp. 

In  cases  where  the  flow  is  scanty  and  the  pain  begins  before  its  appear- 
ance, to  be  relieved  by  its  establishment,  I  have  found  great  benefit  from  the 
use  of  a  rectal  injection  containing  a  heavy  dose  of  sodium  bromide  in  hot 
saline  solution;  it  acts  as  a  local  sedative  and  also  stimulates  the  flow  by 
dilating  the  blood  vessels.     The  formula  for  it  is  as  follows: 

3^    Sodii  bromid gr.   xl 

Hot  saline  sol.,  yo^  of  one  per  cent Oj 

M.     S.  Inject  into  rectum  and  retain. 

Another  rectal  injection  from  which  benefit  is  obtained  is : 

T^   Antipyrini gr.  xv 

Sod.  chlor gr.  xxx 

M o    fSviij 

M.     S.  Inject  into  rectum  and  retain. 


116  DYSMENOEEHEA. 

The  apiilication  of  heat  externally  often  gives  much  relief.  Hot  water 
bags  are  excellent^  or  hot  sand  bags.  A  hot  mustard  foot  bath  is  sometimes 
of  service.  Tor  the  latter  purpose  I  use  two  teaspoonfuls  of  mustard  in  a 
foot-tub  full  of  water,  as  hot  as  can  be  borne. 

In  cases  where  the  pain  is  of  tlie  congestive  character,  T.  A.  Emmet 
recommends  a  plan  of  treatment  directed  to  the  relief  of  venous  engorgement 
("Principles  and  Practice  of  Gynecology,"  3d  edition,  1884,  p.  177).  A  foot 
bath  as  hot  as  can  be  borne  should  be  given,  followed  by  some  kind  of  hot 
drink.  A  hot  mustard  plaster  is  then  applied  along  the  spine.  This  should 
be  about  three  inches  in  width  and  reach  from  the  cervical  region  of  the  spine 
to  the  sacrum.  As  a  rapid  action  is  desired,  the  unadulterated  mustard  must 
be  rubbed  up  into  a  thick  paste  with  warm  water  and  then  reduced  to  the 
proper  consistency  by  adding  an  ounce  or  two  of  syrup  or  molasses,  which  will 
at  once  develop  the  volatile  oil.  A  piece  of  unstarched  muslin,  sufficiently 
long  and  some  nine  inches  in  width,  is  laid  out  at  full  length  and  the  mustard 
is  spread  down  the  middle  for  one-third  of  the  width,  so  that  when  the  strip 
is  folded  over,  the  mustard  will  be  covered  on  one  side  by  two  thicknesses  of 
the  cloth.  The  surface  which  is  covered  by  the  single  thickness  of  cloth  must 
be  warmed  and  kept  folded  together  until  applied.  The  skin  will  become 
reddened  in  from  ten  to  twenty  minutes  and  the  plaster  must  not  be  allowed 
to  remain  longer,  even  though  the  patient  should  not  complain  of  pain  occa- 
sioned by  it.  When  the  flow  is  delayed,  dry  cups,  in  Emmet's  opinion, 
are  more  efficacious  than  the  mustard  plaster  in  bringing  it  on.  These  must 
be  put  on  each  side  of  the  spinous  processes  and  only  in  the  immediate  neigh- 
borhood of  any  point  which  may  be  found  tender  on  pressure.  The  relief  is 
more  prompt  when  four  to  six  large  tumblers  are  used  than  it  is  with  the 
ordinary  sized  cupping  glasses.  Unless  the  tumblers  are  unusually  thick  and 
heavy,  there  is  no  difficulty  in  making  them  hold  on,  after  properly  exhausting 
the  air,  by  igniting  a  little  alcohol  which  has  been  poured  directly  into  the 
glass  or  upon  some  cotton  on  a  piece  of  paper  stuck  to  the  bottom.  The  damp 
cotton  must  be  firmly  pressed  against  the  bottom  of  the  glass  before  dropping 
on  the  alcohol,  and  any  excess  of  alcohol  which  may  have  run  down  to  the 
edge  of  the  glass  carefully  wiped  up  in  order  to  avoid  burning  the  patient. 
Eifteen  to  twenty  minutes  is  long  enough  for  the  cups  to  remain  in  one  place, 
after  which  they  may  be  shifted  to  another.  It  may  be  necessary  to  repeat 
this  treatment  month  after  month  until  the  local  disease  underlying  the  dys- 
menorrhea has  yielded  to  treatment.  During  the  interval  between  the  men- 
strual periods,  the  general  health  must  be  carefully  watched  according  to  the 
rules  laid  down.  A  Turkish  bath  is  often  beneficial  when  taken  within  a 
week  before  the  expected  period. 

When  the  pain  is  intense  and  all  other  remedies  have  failed,  morphin 
may  be  given  hypodermically  as  a  last  resort.  As  a  rule,  a  single  dose  of  one- 
eighth  or  one-fourth  of  a  grain  will  be  sufficient.  It  should  always  be 
controlled   by   the   physician,    and  if  a  marked  neurotic  element  is  pres- 


TKEATMENT    OF    DYSMENOEKIIEA.  117 

ent  he  must  exercise  extreme  caution,  especially  if  the  dose  is  repeated  several 
times.     The  patient  must  be  in  ignorance  of  what  she  is  taking. 

REMEDIES  FOR  PERMANENT  RELIEF  OF  DYSMENORRHEA. 

Pessaries. — Dysmenorrhea  associated  with  retrodisplacements  of  the  uterus 
is  sometimes  relieved  by  a  pessary.  In  one  case  I  found  entire  relief  afforded 
by  one  of  the  Smith-Hodge  variety.  As  to  the  selection  of  a  suitable  pessary 
and  its  application,  see  Chapter  XIII. 

Thyroid  Extract  and  Calcium  Lactate. — Dr.  J.  E.  B.  Branch,  of  Macon,  Ga., 
has  communicated  some  interesting  results  obtained  with  thyroid  extract  and 
also  with  calcium  lactate.  In  one  young  woman  of  twenty-seven,  who  had  suf- 
fered for  twelve  years  with  severe  pains  in  the  lower  abdomen,  backache  and 
headache,  nausea  and  scant  flow,  there  was  complete  relief  obtained  by  giving 
thyroid  extract  5  gT.  t.i.d.  In  several  cases  this  treatment  failed,  and  in  some 
even  made  conditions  worse.  In  two,  splendid  results  were  obtained  by  giving 
10  gr.  of  calcium  lactate  t.i.d.,  beginning  a  week  before  the  expected  onset  of 
period,  continuing  till  its  end. 

Electricity. — The  treatment  of  dysmenorrhea  by  electricity  was  of  interest 
fifteen  years  ago,  and  promised  excellent  results.  The  method  has  failed  be- 
cause of  a  failure  of  interest  in  the  question  of  the  use  of  electricity  in  gyne- 
cology. It  seems  a  matter  for  regret  that  the  electrical  treatment  of  various 
gynecological  affections  should  not  receive  more  attention,  and  I  quote  from  some 
of  the  early  papers  in  hopes  that  the  methods  described  may  be  of  use  to-day. 

W.  B.  Sprague  (Ann.  Gyn.  and  Fed.,  1891,  vol.  4,  p.  402)  says:  "  I  have 
learned  to  take  my  battery  with  me  whenever  called  to  relieve  a  woman  suffer- 
ing at  the  menstrual  period.  I  generally  use  a  Kidder  five-post  battery,  and 
use  the  current  from  the  extreme  posts  (the  A-E  current)  with  the  shell  of  the 
magnet  well  drawn  out.  I  secure  a  current  of  great  tension,  which  is  the  best 
for  relief  of  pain.  Placing  the  positive  electrode,  covered  with  some  absorbent 
material  well  moistened,  in  the  lumbo-sacral  region,  I  use  a  small  electrode  over 
the  hypogastrium  with  a  kneading,  rotary,  and  vibratory  motion.  This  not  only 
relieves  the  pain  greatly,  but  increases  the  flow,  so  the  only  contra-indication  is 
a  tendency  to  menorrhagia.  I  also  use  the  static  and  galvanic  currents  to  pal- 
liate the  pain,  with  less  benefit — the  former  under  similar  conditions  to  those 
in  which  the  faradic  current  is  indicated,  the  latter  in  menorrhagia.  .  .  .  Only 
a  moderate  current  is  required  in  most  cases — from  five  to  twenty-five  milliam- 
peres— but  in  cases  of  severe  hemorrhage  it  is  necessary  to  use  from  fifty  to  sixty 
milliamperes.  Strong  currents,  while  necessary  to  check  hemorrhage,  generally 
increase  the  pain  at  first,  but  cessation  usually  follows,  if  it  be  gradually  re- 
duced and  followed  by  the  sacro-pubic  administration  for  a  few  minutes  fol- 
lowing the  removal  of  the  internal  electrode." 

A.  Lapthorn  Smith  (Amer.  Jour.  Ohst.,  1891,  vol.  26,  p.  161)  states 
that  he  has  found  the  most  important  agent  in  the  treatment  of  dysmenorrhea 
of  uterine  origin  to  be  the  apj^lication  of  the  mild  galvanic  current  to  the 


118  DYSMENOEEHEA. 

inside  of  the  uterus  by  means  of  the  ordinary  uterine  sound,  insulated  to 
within  two  and  a  half  inches  of  its  end,  to  the  handle  of  which  was  attached 
the  negative  pole  of  the  battery.  The  treatment  is  nsnally  less  painful  than 
the  passage  of  the  sound,  as  will  appear  from  the  following  brief  description 
of  the  method :  "  After  a  careful  bimanual  examination  for  the  purpose  of 
excluding  pregnancy  and  ascertaining  the  position  and  condition  of  the  pelvic 
organs,  the  vagina  is  disinfected  by  a  douche,  if  this  has  not  already  been  done, 
at  the  patient's  home.  An  ordinary  Simpson's  uterine  sound  of  large  size  is 
then  bent  to  the  ascertained  curve  of  the  uterine  canal,  passed  through  the 
flame  of  the  spirit  lamp,  cooled,  and  insulated  with  a  clean  piece  of  rubber 
tubing  to  within  two  and  a  half  inches  of  its  extremity,  or  less,  if  we  have 
reason  to  think  that  the  uterus  is  undeveloped.  In  the  handle  of  the  sound 
a  hole  has  been  bored,  just  large  enough  to  hold  the  tip  of  the  conducting  cord 
from  the  negative  pole  or  last  zinc  of  the  battery.  The  sound  is  then  guided 
into  the  os  uteri  on  the  tip  of  the  finger  until  it  meets  with  some  obstruction, 
when  a  current  strength  of  ten  milliamperes  is  turned  on.  In  a  minute  or 
two  the  obstruction  will  seem  to  melt  away  and  the  sound  will  glide  into  the 
cavity  of  the  uterus.  The  current  is  now  gradually  raised  until  the  patient 
says  she  can  feel  it  in  the  uterus,  generally  between  twenty  and  fifty  milliam- 
peres. being  at  once  lowered  on  the  slightest  complaint  of  pain.  At  the  end 
of  five  minutes  the  current  is  gradually  turned  off  again,  when  the  sound  will 
be  found  to  drop  out  almost  of  its  own  accord,  and  very  much  more  easily 
than  it  entered.  This  may  complete  the  seance,  or,  as  an  adjuvant  and  safe- 
guard a  boroglycerid  tampon  may  be  inserted.  The  patient  may  return  home 
on  foot  and  resume  her  duties  forthwith,  as  such  mild  applications  do  not 
require  any  precautions  in  the  way  of  resting,  etc.  The  positive  pole  of  the 
battery  is  attached  to  the  ordinary  clay  abdominal  electrode."  The  following 
case  is  cited  by  Dr.  Smith  as  an  instance  of  the  success  of  the  above  mode  of 
treatment : 

"  ]\Iiss  W.  was  sent  to  me  on  the  third  of  Jime,  1888,  by  Dr.  Eeddy  with 
a  uterine  fibroid  and  an  enormous  hypertrophy  of  the  cervix.  Her  sufferings 
every  month  were  imendiiraljle.  She  had  been  employed  as  cook  in  a  private 
family,  but  had  to  give  up  her  situation,  as  during  menstruation  she  was 
totally  incapacitated.  She  described  the  pain  as  agonizing,  her  screams  being 
heard  all  over  the  house.  I  gave  her  two  applications  a  week  from  then  till 
July  28th  of  the  same  year,  less  than  two  months,  when  she  reported  that  she 
had  had  a  period  absolutely  free  from  pain,  I  continued  to  treat  her  for 
another  month,  but  she  has  never  had  a  painful  period  since,  and  was  still 
menstruating  regiilarly  up  to  a  few  months  ago  when  I  saw  her  last,  in  perfect 
health,  and  doing  all  the  catering  and  cooking  for  a  large  boarding  house." 

A  more  recent  paper  than  these  is  one  by  A.  H.  Goelet  {Internal.  Jour. 
Surg.,  March,  1900).  In  this  he  speaks  most  highly  of  electricity  in  the  treat- 
ment of  dysmenorrhea  associated  with  stenosis,  obstruction,  or  flexion.  In 
cases  of  flexion  it  may  be  necessary  to  use  tampons  in  conjunction,  to  support 


TEEATMENT  OF  DYSMENOKEHEA.  119 

the  uterus  at  a  higher  place  in  the  pelvis  until  its  weight  is  diminished  and  it 
is  no  longer  dragged  down. 

For  the  purpose  of  overcoming  obstruction  in  the  canal,  whether  associated 
with  flexions  or  not,  moderate  electrolysis  is  employed.  This  produces  distinct 
widening  of  the  canal  which  promotes  drainage  of  increased  secretion,  pent 
up  in  the  cavity  as  the  result  of  obstruction.  The  strength  of  the  current 
(galvanic)  employed  for  the  purpose  should  not  exceed  ten  milliamperes,  and 
the  duration  of  the  application  should  be  three  or  four  minutes.  Thus  cauter- 
ization is  avoided  as  obviously  objectionable,  since  it  would  eventually  lead  to 
permanent  stenosis  from  cicatricial  contractions.  The  frequency  of  the  appli- 
cations may  be  every  second  day  for  the  first  week  or  two,  according  to  the 
condition ;  twice  a  week  during  the  third ;  and  cessation  during  the  menstrual 
period.  If  complete  relief  is  obtained  at  this  stage,  one  application  may  be 
made  two  or  three  days  immediately  preceding  the  next  two  succeeding  periods. 
The  electrode  is  inserted  with  a  speculum  in  the  vagina  or  along  the  index 
finger  as  a  guide.  Strict  antisepsis  must  be  preserved  throughout.  The  instru- 
ments and  hands  must  be  clean  and  the  vulva  and  vagina  thoroughly  irrigated 
with  an  antiseptic  solution  immediately  before  treatment.  Following  each 
application  the  pelvis  is  submitted  to  faradization  with  the  current  from  the 
long  fine  wire  coil  by  means  of  the  bipolar  electrode  in  the  vagina  for  the 
purpose  of  overcoming  the  pelvic  hyperemia  which  constantly  accompanies  this 
form  of  dysmenorrhea.  These  applications  should  be  continued  for  ten  to 
fifteen  minutes. 

Goelet  considers  that  dysmenorrhea  due  to  ovaritis  and  salpingitis, 
without  suppuration,  is  amenable  to  this  mode  of  treatment,  if  the  details 
are  carried  out  with  care.  In  these  cases,  particularly  where  there  is  much 
sensitiveness  to  digital  pressure  in  the  vagina,  the  treatment  should  begin  with 
faradization  (bipolar)  through  the  vagina  with  the  most  sedative  current 
obtainable,  and  these  applications,  which  are  repeated  every  twenty-four  hours, 
should  be  continued  each  day  for  fifteen  minutes,  maintaining  the  current 
constantly  throughout  the  application  at  a  point  where  it  is  barely  appreciable 
to  the  patient.  The  strength  of  stimulation  of  the  current  should  be  increased 
only  with  the  decrease  of  sensitiveness.  When  this  has  been  accomplished, 
negative  electrolysis  of  the  canal  is  employed,  when  necessary,  to  promote 
drainage  from  the  uterine  cavity  and  tubes.  In  the  beginning  it  is  best  to 
start  with  an  application  of  only  five  milliamperes  and  continue  it  only  two 
minutes.  The  application  is  repeated  in  two  or  three  days,  if  no  reaction 
follows  to  show  that  it  is  contra-indicated.  The  applications  to  the  canal 
should  be  discontinued  as  soon  as  the  necessity  for  drainage  is  no  longer  indi- 
cated, but  the  faradic  applications  are  to  be  continued  every  second  or  third 
day  until  the  cure  is  complete. 

Dysmenorrhea  due  to  anemia  and  impaired  nutrition  will  yield 
to  vigorous  applications  of  static  electricity,  consisting  of  sparks  over  the  spine 
and  especially  over  the  sacrum;   sparks  to  the  hypogastric  region,   repeated 


120  DYSMENOEEHEA. 

daily,  or  every  second  day;  and  the  application  of  a  stimulating  static  breeze 
applied  generally.  The  applications  are  discontinued  during  menstruation. 
From  two  to  three  months  are  usually  required  to  effect  a  cure. 

Dysmenorrhea  due  to  imperfect  development  of  the  uterus  and 
ovaries  can  only  be  benefited  by  electricity,  if  treatment  is  instituted  before  the 
patient  has  attained  maturity.  The  applications  must  be  made  directly  to  the 
uterus  with  the  object  of  stimulating  this  organ,  and  through  it,  the  ovaries. 
An  electrode  with  two  and  a  quarter  inches  of  exposed  surface  is  inserted  into 
the  uterus  and  connected  with  the  negative  pole  of  the  faradic  apparatus.  The 
other  pole  terminating  in  a  felt  electrode  the  size  of  the  hand,  is  placed  over 
the  lumbar  region  and  the  current  is  employed  as  strong  as  it  can  comfortably 
be  borne.  It  should  be  maintained  for  five  or  ten  minutes  and  its  strength 
constantly  increased  throughout  the  application,  so  as  to  maintain  a  stimula- 
tion throughout,  the  object  being  to  excite  an  increased  blood  flow  to  the  uterus. 
The  applications  should  be  repeated  every  second  day  at  first,  and  later  every 
third  day.  Applications  of  static  electricity  at  the  same  time  will  aid  mate- 
rially by  stimulating  an  increased  general  nutrition.  The  method  which  is 
particularly  effective  is  the  static  breeze:  sparks  to  the  spine,  over  the  sacrum, 
and  to  the  hypogastrium,  with  the  breeze  to  the  head  for  five  to  ten  minutes 
after  the  other  application.  The  static  spark  exercises  a  decided  revulsive 
effect  which  relieves  internal  congestion,  stimulates  the  general  circulation, 
and,  together  wdth  the  breeze,  promotes  nutrition.  The  breeze  to  the  head 
quiets  nervous  irritation  and  induces  natural  sleep. 

It  will  be  seen  that  the  various  advocates  for  the  use  of  electricity  in  gyne- 
cology differ  in  regard  to  the  details  of  its  use,  and  no  doubt  every  practitioner 
who  makes  use  of  it  will  find  it  expedient  to  develop  his  own  method.  It  is  to 
be  hoped  that  gynecologists,  and  general  practitioners  who  practice  more  or 
less  gynecology,  will  give  the  use  of  electricity  in  the  treatment  of  dysmenor- 
rhea a  thorough  trial  during  the  next  few  years,  for  it  would  seem  to  offer  a 
fair  prospect  of  relief  in  certain  intractable  cases,  although  it  is  still  upon 
probation. 

Operative  Treatment. — Permanent  relief  from  dysmenorrhea,  if  other  reme- 
dial measures  fail,  must  be  obtained  from  operative  treatment.  In  cases 
where  the  suffering  is  caused  by  lesions  of  the  pelvic  organs,  the  cure  of  these 
lesions  will  generally  be  followed  by  the  disappearance  of  menstrual  pain,  but 
the  treatment  of  such  cases  belongs  to  the  specialist.  Tor  the  relief  of  dys- 
menorrhea not  associated  with  organic  lesions,  however,  there  is  one  form  of 
operative  treatment  so  simple  as  to  be  within  the  scope  of  the  general  practi- 
tioner, and  therefore  within  the  limits  of  this  work,  namely,  dilatation  of 
the  cervix  uteri,  followed,  when  it  is  indicated,  by  curettage  of  the 
endometrium.  In  cases  where  the  organs  are  apparently  normal  this  mode 
of  treatment  has  yielded  the  following  percentage  of  good  results  in  my  clinic. 
Out  of  ninety-five  cases,  eighteen  were  entirely  relieved  with  no  subsequent 
return  of  the  pain,  and  fourteen  were  greatly  benefited,  the  pain  never  return- 


DILATATION.  121 

ing  to  its  former  severity.  The  periods  of  observation  in  these  cases  extended 
over  from  one  to  twelve  years.  Of  the  remaining  cases,  seven  were  re- 
lieved completely  or  in  great  part  for  periods  of  from  one  to  twelve  years,  after 
which  the  dysmenorrhea  returned.  In  thirty-nine  instances,  therefore,  out  of 
ninety-five,  the  results  might  be  considered  satisfactory.  In  twenty-one  cases 
there  was  no  relief  at  all,  while  the  remaining  thirty-five  cases  experienced 
more  or  less  relief  for  a  few  months,  but  within  a  year  the  pain  returned  in 
the  same  severity  as  before.  When  the  dysmenorrhea  returns  after  a  few 
years  or  months  of  comfort  we  are  justified  in  recommending  a  second 
operation. 

There  is  no  symptom  complex  by  which  the  cases  where  dilatation  may 
be  expected  to  do  good  can  be  differentiated  with  certainty  from  those  in 
which  it  will  not.  In  general,  however,  we  may  anticipate  relief  in  cases 
where  the  pain  begins  a  few  hours  before  the  flow,  is  sharp  in  character,  and 
lasts  but  a  short  time.  A  marked  neurasthenia  does  not  necessarily  forbid  a 
good  result,  but  if  permanency  of  relief  is  to  be  secured,  the  neurasthenia 
must  also  be  cured.  An  excellent  plan  in  such  cases  is  to  institute  a  thor- 
ough rest  cure  by  an  ether  examination  and  a  dilatation,  with 
curettage,    if   necessary. 

DILATATION. 

This  operation  does  not  yet  stand  upon  a  scientific  basis,  for  its  mode  of 
action  is  not  clear  and  its  results  are  far  from  uniform.  It  must  always  be 
borne  in  mind  that  not  every  case  of  dysmenorrhea  is  suitable  for 
dilatation.  The  general  practitioner,  and  even  many  a  specialist,  often 
make  the  mistake  of  beginning  the  treatment  of  every  case  of  dysmenorrhea 
by  dilatation,  without  a  proper  preliminary  search  for  the  cause  of  pain,  for- 
getting that  in  certain  cases  the  pain  is  due  to  the  presence  of  definite  lesions, 
such  as  ovarian  disease,  pelvic  peritonitis,  or  small  interstitial 
fibroids,  which  are  not  of  a  nature  to  be  relieved  by  such  treatment.  In 
order  to  make  clear  the  relation  of  dysmenorrhea  to  a  variety  of  pelvic  affec- 
tions which  are  apt  to  escape  detection  upon  a  superficial  examination,  I 
analyzed  two  hundred  and  fifty-five  cases,  taken  consecutively,  of  pelvic  perito- 
nitis with  adherent  tubes  and  ovaries,  tubercular  peritonitis,  hydrosalpinx,  and 
catarrhal  salpingitis,  and  found  that  out  of  the  two  hundred  and  fifty-five 
cases,  one  hundred  and  eighty  suffered  from  dysmenorrhea,  while  it  was  absent 
in  only  seventy-five  cases. 

If  the  physician  has  determined  by  a  careful  examination  that  no  lesions 
of  the  kind  described  are  present,  and  if  the  various  remedial  meas^ures  have 
been  tried  without  success,  dilatation  should  always  be  performed,  and  fol- 
lowed by  curettage,  if  the  latter  seems  advisable. 

Choice  of  Method. — Slow  dilatation  by  means  of  laminaria  or 
tupelo  tents,  much  used  in  Germany,  has  been  generally  abandoned  in  this 
country,  for  fear  of  septic  infection.     The  class  of  uteri  which  need  dilatation 


122  DYSMENOKKHEA. 

and  curettage  are  often  already  infected,  and  the  introduction  of  a  hard  for- 
eign body  in  the  form  of  a  tent,  which  bruises  and  lacerates  the  tissues  while  it 
is  being  introduced  and  keeps  up  a  constantly  increasing  pressure,  affords  just 
the  condition  most  favorable  to  the  entrance  of  pathologic  organisms  into  the 
system.  In  many  instances  the  patient  recovers  from  the  operation  with  a 
chronic  pelvic  inflammation,  and  not  a  few  deaths  have  been  due  to  sepsis 
originating  in  this  manner.  A  fatal  case  of  infection  following  slow  dilata- 
tion has  been  reported  by  Dr.  T.  S.  Cullen  (Johns  Hopkins  Hosp.  Rep.,  1897, 
vol.  6,  p.  109).  The  patient  was  a  young  woman  whose  physician  had 
thought  it  necessary  to  induce  an  abortion  in  the  fourth  month  of  pregnancy, 
and  therefore  he  inserted  a  slippery  elm  tent  into  the  uterine  cavity.  A  few 
hours  afterwards  the  patient  suddenly  became  deathly  pale  and  fainted  away. 
On  recovering  she  complained  of  great  pain  in  the  abdomen  and  had  a  slight 
uterine  hemorrhage.  Four  days  later  she  had  a  profuse  hemorrhage,  but  it  was 
not  possible  to  ascertain  whether  the  fetus  had  been  expelled.  On  the  fifth 
day  she  had  a  severe  chill,  followed  by  high  temperature,  marked  abdominal 
distention,  and  extreme  tenderness  over  the  abdomen.  The  chills  continued 
at  irregular  intervals  until  the  sixteenth  day,  when  symptoms  of  peritonitis 
appeared  and  death  took  place  at  the  end  of  twelve  hours.  At  the  autopsy  the 
peritoneum  was  found  to  contain  several  quarts  of  purulent  fluid  and  the 
uterus  was  enlarged  and  softened.  It  was  removed,  and  when  the  alcoholic 
specimen  was  examined  it  proved  to  measure  13  X  9  X  6  cm.,  while  its  cavity 
was  9  cm.  in  length.  The  latter  contained  six  pieces  of  wood  (the  component 
parts  of  the  elm  tent),  Avhich,  when  united,  formed  a  perfect  cone  with  a  hole 
perforating  its  base.  The  uterine  walls  were  extensively  necrotic  and  cocci 
were  found  everywhere  in  the  uterine  blood  vessels,  as  well  as  in  the  thin  sheet 
of  fibrin  which  covered  the  uterus  itself.  This  case  is  an  excellent  illustration 
of  the  fact  that  the  tent  ought  only  to  be  used  in  clean  cases,  that  is  to  say, 
where  there  is  no  suspicion  of  any  cervical  or  intra-uterine  infection.  I  would 
not  use  it  in  a  septic  abortion  or  a  sloughing  fibroid. 

Gradual  dilatation  by  means  of  Hegar's  graduated  dilators  has  been 
successful  in  some  cases.  According  to  this  method  dilatation  should  be  begun 
by  dilators,  measuring  3  to  5  mm.  in  diameter,  the  size  being  increased  day 
by  day  during  the  interval  between  menstrual  periods  until  8  to  10  mm.  is 
reached. 

Rapid  dilatation  is,  however,  the  method  now  most  generally  employed 
and  it  is  certainly  the  safest. 

Preliminaries  to  Operation. — The  bowels  must  be  carefully  emptied  by 
means  of  either  a  teaspoonful  of  liquorice  powder  the  night  before  the  opera- 
tion, or  an  equal  amount  of  miagnesium  sulphate  on  the  morning  of  it.  If  it 
seems  necessary,  this  may  be  followed  by  an  enema  of  warm  soap  and  water. 
The  operating  table  is  covered  by  a  sterilized  sheet  and  a  rubber  pad  is  laid 
over  one  end  of  it.  The  patient,  after  being  anesthetized,  is  placed  upon  this 
in  the  lithotomy  position.     The  vagina  is  now  cleansed  with  soap  and  water 


DILATATION. 


123 


on  pledgets  of  cotton  introduced  by  means  of  a  long  forceps.  After  this,  it 
is  irrigated  with  a  solution  of  bichloride  of  mercury,  1 :  1,000.  The  best 
anesthetic  is  nitrous  oxide  gas,  and  if  this  does  not  give  sufficient  relaxation, 
a  few  whiffs  of  ether  may  be  administered  and  the  gas  resumed.  The  whole 
operation  should  not  take  over  five  minutes.     A  careful  bimanual  examination 


Fig.  52. — Instruments  used  in  Dilatation  and  Curettage  of  the  Uterus.  These  instruments  are 
in  order  from  left  to  right,  Sims'  speculxim;  two  traction  forceps;  dressing  forceps;  tliree  iiterine 
dilators;  two  serrated  curettes;  one  gauze  packer;  one  uterine  sound;  bottle  of  formalin  solution  for 
specimen  secured. 

of  the  pelvic  organs  should  always  be  made  while  the  patient  is  under  the 
anesthetic.  ISTot  only  does  it  afford  valuable  information  as  to  her  condition, 
but  if  the  direction  of  the  uterine  canal  is  known,  it  greatly  aids  the  intro- 
duction of  the  dilators.     The  instruments  used  are  shown  in  Figure  52. 

Operation  of  Rapid  Dilatation. — In  the  virgin  the  well-anointed  index  finger 
must  be  introduced  into  the  vagina  slowly  and  gently,' to  avoid  injuring  the 
hymen.  When  the  finger  touches  the  cervix,  a  pair  of  tenaculum  forceps  is 
introduced  and  the  cervix  firmly  grasped  by  its  anterior  lip.  The  finger  is  then 
withdrawn,  and  traction  made  with  the  forceps  until  the  os  uteri  is  seen  at 
the  vaginal  outlet  (see  Fig.  53).  When  the  orifice  is  small,  or  the  examining 
finger  large,  the  position  of  the  cervix  must  be  determined  without  vaginal 
examination  by  a  careful  rectal  palpation,  in  order  to  avoid  injuring  the 
hymen,  after  which  the  tenaculum  forceps  are  introduced  into  the  vagina,  and 
under  the  guidance  of  the  rectal  finger  the  anterior  lip  of  the  cervix  is  cau- 


124 


DYSMENOEKHEA. 


tiouslj  drawn  down  to  the  outlet.  In  married  women,  and  in  those  who  have 
borne  children,  the  posterior  vaginal  wall  may  be  readily  retracted  by  a  Sims' 
or  a  Simon  speculum  or  even  with  two  fingers,  so  as  to  expose  the  cervix, 
which  is  then  grasped  by  the  tenaculum  forceps  and  drawn  down. 


Fig.  53. — ^The  Cervix  Caught  and  Exposed  by  Retracting  the  Posterior  Vaginal  Wall  with  a 
Speculum,  Grasping  the  Anterior  Lip  with  a  Bullet  Forceps,  and  Drawing  it  Down  to 
the  Vaginal  Outlet. 

Dilators  of  the  Goodell-Ellinger  pattern  of  three  sizes  are  needed 
(see  Fig.  52).  The  smallest  of  these,  which  has  smooth  blades,  is  4  mm.  in 
diameter,  while  the  two  larger,  which  are  5  and  6  mm.  in  diameter,  respectively, 
are  both  corrugated,  as  recommended  by  the  late  Dr.  William  Goodell.  My 
own  dilators  have  a  spring  between  the  handles,  but  are  not  provided  with 
either  ratchet  or  screw.  The  handles  are  bent  at  an  angle  and  are  made  large 
enough  to  be  grasped  in  the  full  hand;  the  dilating  end  is  blunt  and  slightly 
curved.  Light  instruments  with  a  strong  curve  and  a  tapering  point  are  dan- 
gerous and  must  not  be  used. 

The  smallest  dilator  is  now  taken  up,  poised  delicately  between  the  fingers 
like  a  pen,  and  gently  introduced  within  the  external  os,   after  which  it  is 


DILATATIOlSr. 


125 


pushed  np  the  canal  to  the  internal  os  (see  Fig.  54).  The  dilator  must  never 
be  grasped  with  the  handles  braced  against  the  palm  of  the  hand  and  forced 
through  obstructions.  When  resistance  is  encountered,  as  it  commonly  is,  in 
passing  from  the  internal  os  into  the  uterine  cavity,  the  dilator  must  be  with- 
drawn a  little  until  by  repeated  efforts  and  without  force,  it  finally  passes  the 
obstruction  and  slips  in.  The  danger  of  forcing  a  sharp  dilator  into 
the  uterine  canal  without  due  precaution  is  considerable.  I 
have  seen  a  death  resulting  from  neglect  of  the  precaution  (Amer.  Jour.  Ohst., 
1891,  vol.  24,  p.  42).  The  surgeon  pierced  the  posterior  wall  of  an  ante- 
flexed  uterus  at  its  cervical  junction  and  bored  a  hole  into  the  peritoneum. 
He  then  inserted  a  coarse  sponge  tent  into  the  cervix,  which  projected  partly 
within  the  peritoneal  cavity.  The  patient  died  in  a  few  days  of  peritonitis, 
in  spite  of  an  effort  which  I  made  to  save  her  by  opening  and  draining  the 


Fig.   54. — Dilatation    of   the    Cervix   with   the    Goodell-Ellenger    Dilator. 


abdomen.  The  risk  of  perforating  an  anteflexed  uterus  is  so  manifest  that  I 
cannot  avoid  the  conviction  that  such  an  accident  has  happened  more  fre- 
quently than  is  generally  known. 

The  blades  of  the  dilator  being  well  introduced,  the  canal  is  first  dilated 
in  one  direction ;  the  pressure  is  then  relaxed  and,  when  the  blades  have  closed, 
the  dilator  is  rotated  a  little,  so  as  to  dilate  another  portion  of  the  canal,  this 


126  DTSMENOEKHEA. 

process  being  continiied  all  around  the  circle  back  to  the  first  point.  The 
cervix  yields  to  these  repeated  gentle  impacts  from  within  on  all  sides  and  is 
gradually  and  equably  dilated  to  the  necessary  extent  without  laceration.  In 
this  way  the  canal  is  opened  up  within  a  minute  or  two,  sufficiently  to  admit 
a  large  corrugated  dilator  with  which  the  dilatation  is  continued  in  like  manner 
from  side  to  side,  antero-posteriorly  and  at  all  points  between. 

This  extent  of  dilatation,  which  is  large  enough  to  admit  the  introduction 
of  a  bougie  1  cm.  in  diameter,  is  usually  sufficient  for  the  relief  of  dysmenor- 
rhea ;  a  somewhat  greater  dilatation  may  be  obtained  by  using  the  largest  size 
dilator,  but  not  without  risk  of  great  injury  to  the  cervix.  It  is  never  justi- 
fiable to  attempt  the  dilatation  of  the  cervical  canal  sufficiently  to  permit  the 
introduction  of  the  index  finger  into  the  uterine  cavity,  for  it  can  be  accom- 
plished only  by  extensive  rupture  of  the  cervix. 

The  method  just  described,  in  which  the  cervical  canal  is  dilated  through 
successive  impacts  on  it  from  all  directions,  is  far  better  than  the  common 
method  of  opening  a  dilator  controlled  by  a  ratchet  or  screw  and  expending 
all  the  force  in  one  direction  until  the  fibres  split  and  a  tear  is  produced.  The 
damage  done  the  cervix,  the  gTcater  danger  of  septic  infection,  and  the  possi- 
bility of  cancer  developing  in  the  scar  which  remains  after  the  rent  heals, 
are  great  objections  to  forcible  dilatation  in  one  direction. 

In  many  cases  it  is  advisable  to  follow  up  the  dilatation  by  curettage,  and 
the  method  for  doing  this  will  be  found  in  Chapter  VII. 

After  dilatation  the  patient  should  be  kept  in  bed  for  from  one  to  fourteen 
days,  according  to  conditions.  If  her  general  health  is  good  and  her  nervous 
system  undisturbed,  twenty-four  hours  will  be  sufficient ;  but  if  she  is  anemic 
and  reduced  by  continued  suffering,  advantage  should  be  taken  of  the  oppor- 
tunity afforded  by  the  operation  to  give  her  as  long  a  rest  as  possible,  with  the 
advantage  of  care,  attention  to  diet,  and  other  essentials  to  complete  recovery. 
A  neurasthenic  patient  should  always  be  kept  in  bed  after  the  operation  for 
ten  days  to  a  fortnight. 

Dilatation,  as  I  said,  is  the  only  form  of  operative  treatment  for  dys- 
menorrhea which  comes  within  the  scope  of  this  work.  Removal  of  the 
ovaries  in  intractable  cases,  however,  sometimes  comes  before  the  general  prac- 
titioner, because  his  advice  is  sought  as  to  its  advisability  by  the  patient  or  her 
relatives.  I  cannot  leave  the  subject  without  speaking  emphatically  against 
such  a  practice.  The  removal  of  diseased  ovaries  is  an  entirely  different  mat- 
ter; the  removal  of  healthy  ovaries  for  the  relief  of  dysmenor- 
rhea is  almost  never  justifiable.  The  only  occasions  in  which  it 
can  ever  be  so,  are  the  rare  instances  in  which  long  continuance  of  pelvic  pain 
is  wrecking  the  patient's  health  and  disabling  her  to  such  an  extent  that  she  is 
incapacitated  for  self  support  or  for  the  performance  of  imperative  household 
duties.  In  an  extensive  gynecological  practice  I  do  not  think  I  average  one 
case  a  year  of  this  kind.  The  patient's  word  or  that  of  her  relatives  must 
never  be  taken  as  a  gauge  of  the  amount  of  suffering  experienced,  for,  with 


EEASONS    AGAINST    REMOVING    OVARIES    TO    RELIEVE    DYSMENORRHEA.         127 

every  intention  to  be  honest  and  avoid  exaggeration,  it  is  almost  impossible  for 
them  to  be  accurate.  If  such  a  measure  is  in  contemplation,  the  physician 
must  convince  himself  of  the  intensity  of  the  pain  by  his  own  observation  of 
the  patient  through  several  periods.  The  effect  upon  her  general  health 
is  also  a  reliable  test.  So  long  as  the  suffering  is  confined  to  the  men- 
strual periods,  and  the  interval  is  free  from  pain,  the  patient's  health  rarely 
suffers  to  any  great  degree;  if,  however,  as  sometimes  happens,  she  is  never 
wholly  exempt  from  pain,  some  degree  of  neurasthenia  is  almost  certain  to 
ensue,  with  loss  of  appetite,  sleep,  and  general  impairment  of  physical  con- 
dition. Under  such  circumstances  as  these  the  patient  loses  v/eight  and 
strength,  her  face  acquires  a  haggard,  anxious  expression,  and  there  is  every 
indication  to  the  practiced  eye  that  her  general  health  is  much  impaired. 

Another  point  upon  which  I  should  like  to  lay  stress  in  this  connection  is 
that  the  fact  of  ovaries  being  cystic  is  no  reason,  per  se,  for  their  removal. 
It  is  not  definitely  decided  whether  any  clinical  symptoms  arise  from  the  cystic 
follicles  from  the  size  of  a  pea  to  that  of  a  cherry,  which  are  often  observed. 
One  thing  is  quite  certain,  however,  namely,  that  small  cystic  follicles 
never  of  themselves  justify  the  removal  of  an  ovary,  or  a  piece 
of  an  ovary.  The  removal  of  one  ovary  is  sometimes  suggested  for  the 
reason  that  it  is  "  down,"  but  this  expression  is  just  about  as  scientific  as 
saying  that  the  palate  is  "  down  and  needs  cutting." 

How  great  may  be  the  influence  for  good  of  the  conscientious  general  prac- 
titioner in  cases  of  this  kind  is  shown  by  the  following  case  which  recently 
passed  through  my  hands : 

A  young  woman  of  two  or  three  and  twenty  was  brought  to  me  with  the 
following  history :  About  two  years  before  she  had  begun  to  suffer  from  dys- 
menorrhea after  a  fall  from  her  horse.  She  lived  in  the  country,  on  a  farm, 
where  no  medical  attendance  was  within  reach  except  that  of  the  general  prac- 
titioner in  the  neighborhood.  He  attended  her  for  some  time  without  success, 
and  then,  finding  that  she  was,  if  anything,  worse  and  that  her  limited  means 
prevented  her  coming  to  the  city  to  consult  a  gynecologist,  he  suggested  asking 
the  advice  of  a  well-known  general  surgeon  who  passed  his  summer  holidays 
in  the  neighborhood.  The  surgeon  made  a  pelvic  examination  and  advised 
the  removal  of  one  ovary,  on  the  ground  that  it  was  cystic.  This  he  did  and 
for  a  short  time  the  patient  improved,  but  within  six  months  she  was  suffering 
as  much  as  ever.  The  same  surgeon  was  again  consulted  and  insisted  that 
the  only  possible  remedy  was  the  removal  of  the  other  ovary.  The  patient 
and  her  family  consented,  with  reluctance,  but  fortunately  for  the  issue,  the 
country  physician,  who  still  had  the  case  in  charge,  set  before  them  earnestly 
that  the  removal  of  both  ovaries  in  a  girl  not  much  over  twenty,  who  was, 
moreover,  engaged  to  be  married,  w^as  too  serious  a  step  to  contemplate  without 
the  opinion  of  a  competent  gynecologist  as  to  its  necessity,  and  that  it  was 
their  duty  to  make  an  effort  to  obtain  this,  no  matter  what  exertion  or  sacri- 
fice it  involved.     Accordingly,  the  patient  was  brought  to  me,  and  I  made  an 


128  DYSMENOEKHEA. 

examination  under  ether,  at  which  I  found  nothing  whatever  the  matter.  I 
dilated  and  curetted,  however,  thinking  the  case  one  where  it  was  likely  to  be 
beneficial,  and  the  patient  has  ever  since  (nearly  five  years)  been  free  from 
anything  more  than  a  trifling  amount  of  pain.  Yet  her  whole  future  would 
have  been  sacrificed  had  it  not  been  for  the  influence  of  her  physician. 

MEMBRANOUS    DYSMENORRHEA.* 

There  is  one  kind  of  painful  menstruation  so  peculiar  as  to  demand  special 
consideration.  This  is  the  form  known  as  "  membranous  dysmenorrhea,"  char- 
acterized by  severe  cramp-like  pains,  resembling  those  of  labor,  followed  by  the 
expulsion  of  the  lining  membrane  of  the  uterus,  either  whole  or  in  part.  The 
cases  vary  in  severity  from  the  typical  form  in  which  a  complete  cast  of  the 
uterine  cavity  is  discharged  at  each  period  with  great  suffering,  to  a  mild  type 
where  only  small  fragments  of  the  endometrium  are  discharged  at  intervals 
of  several  months,  with  a  trivial  amount  of  pain.  When  the  membrane  is 
passed  entire,  which,  however,  rarely  happens,  its  nature  can  be  readily  recog- 
nized by  floating  it  in  water ;  a  shaggy  outer  coat  can  then  be  distinguished, 
of  narrow  triangiilar  form,  with  little  openings  at  the  base  corresponding  to 
the  tubal  orifices  and  a  larger  opening  corresponding  to  the  internal  os.  The 
affection  is  not  a  disease  sui  generis,  but  a  condition  which  develops  under 
varying  conditions,  complicates  different  pathological  processes,  and  presents 
a  variety  of  microscopic  appearances.  Some  writers  have,  therefore,  suggested 
that  the  term  "  membranous  dysmenorrhea  "  should  be  abandoned  in  favor  of 
"exfoliative  endometritis"  (Wyder,  Arch.  f.  Gyn.,  1878,  voL  13,  p.  39)  or 
*'  exfoliation  of  the  menstrual  mucosa "  (Lohlein,  Zeitschr.  f.  Geh.  u.  Gyn., 
1886,  vol  12,  p.  465). 

History. — The  condition  was  first  recognized  by  MorgagTii  ("  De  Sedibus 
et  Causis  Morborum,"  1779,  Bk.  Ill,  Letter  48),  who  reported  a  case  and  gave 
an  excellent  description  of  its  clinical  course.  The  first  microscopic  study 
of  the  membrane  was  made  by  Ernst  Heinrich  Weber,  and  the  term  "  mem- 
branous dysmenorrhea  "  was  given  in  1846  by  Oldham  (London  Med.  Gaz., 
1846)  and  Simpson  (Edin.  Med.  Jour.,  1877).  The  resemblance  to  decidual 
tissue  excited  a  prolonged  discussion  in  Germany  as  to  whether  all  cases  of 
membranous  dysmenorrhea  were  not  really  early  abortions,  and  it  is  only 
within  the  last  thirty  years  that  the  two  conditions  have  been  clearly  differ- 
entiated. The  first  adequate  histological  study  in  modern  literature  is  that 
by  Wyder  (loc.  cit.).  Von  Franque,  in  1893,  made  an  elaborate  study  of  the 
pathological  anatomy  (Zeitschr.  f.  Geh.  u.  Gyn.,  1893,  vol.  27,  p.  1),  and 
since  then  numerous  isolated  cases  have  been  reported,  but  little  new  infor- 
mation has  been  added  to  the  subject. 

*A  paper  by  Dr.  Elizabeth  Morse  {Johns  Hopkins  Hospital  Bulletin,  1907,  vol.  18,  p.  40), 
which  is  based  upon  an  investigation  of  four  cases  of  membranous  dysmenorrhea  in  my  clinic, 
is  the  foimdation  of  this  section. 


MEMBRANOUS  DYSMENORKHEA.  129 

Etiology.. — The  etiology  and  pathogenesis  of  the  condition  are  obscure, 
partly,  no  doubt,  because  the  affection  is  really  rare  and  specimens  for  study 
are  not  often  available.  The  most  important  etiological  factor  is  a  preceding 
endometritis,  arising  after  childbirth,  abortion,  or  a  gonorrheal  infection. 
In  some  cases  there  is  a  retroflexion  of  the  uterus  or  some  abnor- 
mality of  the  appendages.  A  considerable  number  of  cases,  however,  occur 
in  young  unmarried  women,  where  there  is  no  history  of  infection  and  the 
pelvic  organs  on  examination  are  apparently  normal.  In  these  cases  there 
is,  of  course,  the  possibility  of  an  overlooked  vaginitis  in  childhood  or  an 
endometritis    accompanying  one  of  the    exanthemata. 

Clinical  History. — In  the  first  class  of  cases,  where  there  is  a  history  of 
infection,  menstruation  is  usually  regular  and  normal  until  a  labor  or  an 
abortion  takes  place,  followed  by  fever ;  or,  it  may  be,  there  is  an  attack  of 
gonorrheal  endometritis.  After  the  occurrence  of  some  such  cause,  dysmen- 
orrhea appears  and  is  accompanied,  in  the  course  of  a  few  months,  by  extrusion 
of  the  menstrual  membrane.  In  the  second  class  of  cases,  where  the  pelvic 
organs  are  normal,  the  menstrual  history  shows  no  irregularities  and  the  dys- 
menorrhea, followed  by  the  expulsion  of  the  membrane,  appears  without  any 
perceptible  exciting  cause  whatever.  In  both  classes  the  pain  is  intermittent 
and -cramp-like  in  character,  closely  resembling  labor  pains,  and  the  membrane 
is  usually  passed  on  the  second  or  third  day  of  menstruation.  After  the  mem- 
brane is  discharged,  the  pains  cease  and  there  is  often  a  copious  flow. 

Macroscopic  Appearance. — The  menstrual  membrane,  when  it  is  discharged, 
forms  a  triangular  sac,  having  the  shape  of  the  uterine  cavity ;  sometimes  it 
has  rounded  holes  at  the  sides  of  the  tubal  openings.  The  "outer  surface  is 
ragged ;  the  inner  smooth.  The  thickness  of  the  membrane  varies  from  that 
of  tissue  paper  to  two  or  three  millimetres.  A  membrane  of  greater  thickness 
suggests  decidua.  Complete  casts  of  the  uterine  cavity  are  more  rarely  found 
in  membranous  dysmenorrhea  than  in  pregnancy.  In  the  majority  of  cases 
the  membrane  is  passed  in  fragments. 

Microscopic  Appearance. — From  a  microscopic  point  of  view,  the  membranes 
discharged  from  the  uterus  may  be  divided  into  two  classes,  namely,  exfoli- 
ated mucosa  and  fibrinous  easts.  In  the  first  class  of  cases,  exfoliated 
mucosa,  there  are  two  different  types.  One  of  these  is  that  of  interstitial 
endometritis,  in  which  the  stroma  cells  are  of  normal  size  and  appearance 
and  there  is  an  infiltration  of  leucocytes.  Hemorrhage,  exudate,  and 
fibrin  are  usually  present  in  addition.  In  the  other  type  the  stroma  cells 
bear  a  strong  resemblance  to  decidua.  They  are  enlarged,  oval  or  polygonal 
in  form,  and  have  large  vascular  nuclei  with  abundant  protoplasm ;  all  grada- 
tions may  be  traced  between  them  and  the  normal  stroma.  In  some  cases  the 
entire  membrane  is  composed  of  these  altered  cells,  while  in  others,  glands 
exist;  occasionally  two  layers,  one  compact  and  one  spongy,  can  be  distin- 
guished. It  often  happens  that  the  two  types  are  found  in  the  same  membrane. 
The  large  stroma  cells  are  usually  supposed  to  be  the  result  of  hyperemia  and 
10 


130  DYSMENORKHEA. 

irritation.  Tliej  are  not  peculiar  to  this  condition,  but  are  found  also  in 
glandular  lijpertropliy  and  edema  of  tlie  endometrium,  where  they  are  ac- 
counted for  by  circulatory  changes. 

In  the  second  class  of  cases,  the  fibrinous  casts  are  composed  of 
a  network  of  fibrin,  containing  in  its  meshes  red  corpuscles,  leucocytes, 
and  remnants  of  the  cells  of  the  mucosa.  There  is  some  difference  of  opinion 
as  to  whether  this  second  group  of  cases  should  be  considered  as  true  cases 
of  membranous  dysmenorrhea.  They  develop,  however,  in  connection  with 
endometric  processes  and  are  passed  with  the  same  symptoms  as  organized 
membranes ;  in  fact,  cases  have  been  rej3orted  where  a  patient  passed  a  fibrinous 
cast  at  one  time  and  a  membrane  of  altered  mucosa  at  another.  Moreover, 
it  is  impossible  to  separate  the  two  varieties  anatomically,  on  account  of  the 
many  transitional  forms  between  the  simple  fibrinous  casts  and  the  well  pre- 
served endometrium. 

Mechanism  of  Separation. — The  mechanism  of  separation  of  the  membrane 
is  obscure.  The  theory  most  generally  accepted  is  that  the  hyperj)lasia  of  the 
stroma  cells  causes  an  obstruction  to  the  escape  of  blood  into  the  superficial 
layers,  and  therefore  it  spreads  out  into  the  deeper  portions  of  the  uterus, 
which  yields  at  the  weakest  point  on  account  of  the  friability  due  to  chronic 
hyperemia  and  the  youth  of  the  connective  tissue  cells.  The  membrane  is,  so 
to  speak,  dissected  free  by  hemorrhage.  The  free  bleeding  which  so  fre- 
quently follows  the  expulsion  of  the  cast  is  in  favor  of  this  view;  while,  on 
the  other  hand,  the  fact  that  blood  is  often  found  distributed  through  all  parts 
of  the  membrane  is  supposed  to  be  against  it.  The  degenerative  changes  which 
are  taking  place  in  the  membrane  must  also  be  an  important  factor  in  causing 
separation. 

Diagnosis. — The  clinical  history  of  membranous  dysmenorrhea  is,  of  course, 
extremely  suggestive  of  the  diagnosis,  nevertheless,  it  can  never  be  positively 
made  without  a  microscopic  examination,  for  there  are  two  other  kinds 
of  casts  discharged  from  the  vagina  which  may  simulate  the  menstrual  mem- 
brane to  the  naked  eye.  These  are  vaginal  casts  and  decidual  casts. 
Vaginal  casts  are  thrown  off,  either  as  the  result  of  an  exfoliative  vaginitis 
or  of  treatment  of  the  vagina  with  strong  chemicals,  such  as  silver  nitrate. 
In  the  case  of  exfoliative  vaginitis  the  tissue  may  be  passed  during  men- 
struation or  independently  of  it,  but  if  the  discharge  occurs  with  menstrua- 
tion and  is  accompanied  by  suffering  of  a  cramp-like  character,  the  case  may 
readily  be  mistaken  for  one  of  membranous  dysmenorrhea.  How  easily  a 
mistake  may  be  made  in  the  absence  of  a  microscopic  examination  is  shown 
by  the  fact  that  out  of  eleven  specimens  sent  to  my  laboratory  at  the  Johns 
Hopkins  Hospital  with  the  diagnosis  of  "  membranous  dysmenorrhea,"  only 
four  proved  to  be  genuine.  The  others  showed  decidua  in  three  instances  and 
vaginal  epithelium  in  two;  while  of  the  remaining  two  specimens,  one  was 
uterine  polyp  and  the  other  blood  clot.  It  must  always  be  remembered  that 
an  exfoliative  vaginitis  may  accompany  membranous  dysmenorrhea,  and  Leo- 


MEMBEANOUS    DYSMEKOKEHEA.  131 

pokl,  who  rejDorts  a  case  of  this  kind  (Arch.  f.  Gyn.,  1876,  voL  10,  p.  293), 
considers  the  cause  of  the  two  processes  the  same,  namely,  a  superficial  hem- 
orrhage arising  from  extreme  hyperemia  and  extending  through  the  cervix  into 
tne  vagina.  Hoggan  (Arch.  f.  Gyn.,  1876,  vol.  10,  p.  301)  describes  a  case 
in  which  the  upper  part  of  the  membrane  was  composed  of  uterine  mucosa  and 
the  lower  of  vaginal  epithelium.  As  a  rule,  vaginal  casts  and  pieces  of  vaginal 
tissue  are  thinner,  rougher,  and  more  like  parchment  than  membranes  from 
the  uterus,  and  no  glandular  openings  are  seen  upon  the  surface.  In  differ- 
entiating from  decidual  casts  the  history  must  first  be  considered,  since  this 
form  of  cast  is  larger  and  more  vascular  than  those  of  the  dysmenorrheic  mem- 
brane, and  if  chorion-like  villi  be  found  on  microscopic  examination,  the  diag- 
nosis of  extra-uterine  pregTiancy  is,  of  course,  clear.  If  decidua  alone  are  pres- 
ent, it  is  a  case  of  normal  pregnancy.  In  an  interesting  case  of  my  own  the 
patient  brought  me  two  casts,  one  of  which  had  been  passed  with  menstrua- 
tion, while  the  other,  which  appeared  after  the  interval  of  a  month,  w^as  an 
extra-uterine  pregnancy.  The  greatest  difficulty  arises  in  cases  where  it  is 
necessary  to  make  a  differential  diagnosis  between  an  early  abortion  and  a  men- 
strual membrane  containing  the  decidua-like  cells.  This  question  occurs  usu- 
ally in  cases  of  early  abortion,  before  the  decidua  has  reached  its  full  develop- 
ment and  typical  form.  The  diagnosis  must  rest  upon  the  fact  that  the  cells 
in  the  menstrual  membrane  do  not  show  the  enlarged  epithelioid  appearance 
so  often  found  in  the  mature  decidual  cell,  and  also  that  they  have  a  more 
abundant  protoplasm  with  more  sharply  defined  outlines.  Moreover,  the  pro- 
toplasm of  the  decidual  cell  loses  its  fibrillated  appearance  and  takes  a  deeper 
eosin  stain.  The  diagnosis  can  usually  be  made  upon  the  microscopic  evidence 
alone,  but  cases  sometimes  occur  in  which  the  final  decision  must  include  the 
clinical  history. 

Treatment. — The  treatment  in  membranous  dysmenorrhea  is  discouraging, 
and  the  prognosis  as  to  recovery,  either  with  or  withoiTt  it,  is  not  good.  When 
the  underlying  condition  is  obscure,  the  treatment  most  often  adopted  is 
curettage  a  few  days  before  menstruation,  followed  by  the  classical  appli- 
cation of  iodine  or  carbolic  acid  and  glycerin  to  the  uterine  cavity. 
This  procedure  may  give  temporary  relief,  but  the  patient  generally  relapses 
within  a  few  months.  Any  associated  lesions  or  abnormalities  of  the  uterus  or 
appendages  should,  of  course,  receive  appropriate  treatment.  Sterility  is  the 
rule  in  membranous  dysmenorrhea,  although  a  few  patients  recover  and  become 
pregnant. 


CHAPTEE    V. 

INTERMENSTRUAL   PAIN. 

Definition,  p.  132.  History,  p.  132.  Age,  p.  133.  Relation  to  sterility,  p.  133.  Relation  to 
child-bearing,  p.  133.  Date  of  pain,  p.  134.  Character  of  pain,  p.  135.  Dui-ation  cf 
pain,  p.  135.  Period  of  time  dui'ing  which  pain  lasts,  p.  136.  Pressure  and  nature  of 
discharge,  p.  135.  Relation  to  menstruation,  p.  135.  Location  of  pain,  p.  135.  Relation 
to  lesions  found  on  examination,  p.  135.  Methods  of  treatment  and  their  results,  p.  136. 
niustrative  cases,  p.  137.     Conclusions,  p.  138. 

Definition. — Intermenstrual  pain  is  the  name  given  to  a  form  of  suffering 
characterized  by  pelvic  pain  occurring  on  a  fixed  date  between  two  menstrual 
periods,  in  some  cases  midwav  between,  and  in  others  on  a  definite  date  after 
the  preceding  period  or  before  the  following  one.  The  Germans  give  the 
name  "  Mittelschmerz  "  to  this  affection,  but  this  does  not  seem  an  accu- 
rate designation,  since  the  pain  does  not  always  occur  in  the  middle  of  the 
intermenstrual  periods.  iSTor  does  the  term  "intermediate  dysmenor- 
rhea" appear  more  appropriate,  for  the  special  characteristic  of  the  pain  is 
that  it  occurs  in  the  interval  between  the  menstrual  periods  and  is,  therefore, 
distinct  from  dysmenorrhea.  The  term  used  by  the  French,  "  douleurs 
intermenstruelles,"  or  its  English  equivalent,  "intermenstrual  pain," 
seems  the  most  exact,  as  well  as  the  most  descriptive  name  for  this  affection. 

History. — The  disorder  was  first  described,  so  far  as  I  know,  by  Sir  William 
Priestley  in  1872.  He  then  reported  four  cases,  selected,  he  says,  from  a 
number  of  others  {Brit.  Med.  Jour.,  1872,  vol.  2,  p.  131).  Priestley  says 
frankly  that,  at  the  time  at  which  he  WTote,  any  opinion  as  to  the  nature  and 
causation  of  the  affection  was  purely  conjectural,  and  the  years  that  have 
elapsed  have  contributed  little  to  our  knowledge  on  the  subject.  Priestley's 
theory  regarding  it  is  based  on  the  fact  that  shortly  before  menstruation  one 
or  both  ovaries  become  turgescent,  an  event  known  to  take  place,  and  this  tur- 
gescence  lasts  through  the  menstrual  period,  continues  for  a  few  days  after  its 
cessation,  and  then  gradually  subsides.  In  Priestley's  opinion  it  is  not  unrea- 
sonable to  suppose  that  the  preparation  for  an  approaching  period  should  take 
place  as  much  as  ten  to  fourteen  days  before  its  OQCurrence.  Under  normal 
conditions  this  preparation  is  not  accompanied  by  any  appreciable  signs ;  but 
the  presence  of  abnormal  conditions  in  the  ovary,  or  even  of  undue  excitability 
where  no  structural  change  is  apparent,  may  cause  the  preparatory  stage  to  be 
as  difficult  and  painful  as  the  later  stages,  which  are  accompanied,  in  many 
cases,  by  painful  menstruation. 
132 


KELATIONS    OF    INTEEMENSTEUAL    PAIN".  133 

Since  the  appearance  of  Priestley's  article  cases  of  intermenstrual  pain 
have  been  reported  from  time  to  time,  sometimes  accompanied  with  suggestions 
as  to  its  etiology.  In  looking  over  the  literature  of  the  subject  I  have  been 
surprised  to  find  that  although  the  total  number  of  cases  definitely  reported 
is  small,  most  of  the  formal  reports  are  followed  by  the  mention  of  other  cases 
occurring  in  the  practice  of  those  present;  so  that  it  would  seem  the  affec- 
tion is  by  no  means  so  uncommon  as  it  is  usually  believed  to  be,  and  it  is 
possible  that  if  all  the  cases  coming  under  observation  were  carefully  recorded, 
some  definite  conclusions  might  be  reached  as  to  its  nature  and  etiology.  I 
have  collected  all  the  cases  which  I  could  find  in  the  literature,  and  after  add- 
ing fourteen  from  my  own  case-books,  I  have  made  a  careful  analysis  of  the 
whole  number,  sixty-four.  Space  does  not  permit  me  to  give  any  detailed 
account  of  so  large  a  number  here ;  I  must  confine  myself  to  a  brief  statement 
of  the  main  points  brought  out  by  the  analysis,  adding  a  few  illustrative  cases 
from  my  own  records. 

Age. — The  age  at  which  intermenstrual  pain  began  was  noted  in  forty-one 
out  of  the  sixty-four  cases.  In  only  three  did  it  begin  with  first  menstrua- 
tion; in  all  the  others  menstruation  had  been  established  for  some  years  before 
it  appeared.  In  ten  cases  (including  the  three  beginning  with  first  menstrua- 
tion) the  patient  was  under  twenty  when  the  pain  began ;  twenty-nine  of  the 
remaining  cases  were  between  twenty  and  thirty-five ;  while  two  were  over 
thirty-five.  It  seems  reasonable,  therefore,  to  conclude  that  intermenstrual 
pain  is  an  affection  belonging  to  the  period  of  full  sexual  activ- 
ity. Besides  these  forty-one  cases,  there  were  twenty-three  in  which  the  age 
of  the  patient  when  intermenstrual  pain  began  was  not  stated,  and  could  not 
be  calculated  from  the  other  data.  In  seven  out  of  the  twenty-three,  however, 
the  age  of  the  patient  when  she  came  under  observation  was  given,  six  of  them 
being  between  twenty  and  thirty-five,  while  one  was  forty-eight. 

Sterility. — Out  of  the  sixty-four  cases,  thirty-two  had  never  had  children 
or  miscarriages  (eleven  of  them  being  married  and  twenty-one  single).  Thir- 
teen had  had  neither  children  nor  miscarriages  for  as  much  as  five  years,  and 
in  most  cases  much  longer.  Fourteen  had  had  children,  or  miscarriages,  or 
both,  within  five  years ;  and  the  condition  of  five  as  regards  child-bearing  was 
not  stated.  Or,  to  put  the  matter  in  another  form,  thirty-two  cases  were  sterile ; 
thirteen  relatively  sterile;  fourteen  fertile;  and  five  unknown.  These  results 
seem  to  support  the  statement  made  by  some  persons  that  intermenstrual 
pain  is  associated,  in  the  majority  of  cases,  with  sterility. 

Relation  between  Intermenstrual  Pain  and  Child-bearing. — Of  the  fourteen 
cases  in  which  the  patient  had  had  either  children  or  miscarriages,  there  were 
five  in  which  the  pain  began  after  the  birth  of  the  last  child,  and  three  in 
which  it  began  after  a  miscarriage.  In  six  cases  it  was  not  stated  whether 
the  pain  began  before  or  after  preg-nancy.  It  would  seem,  therefore,  that  it 
is  at  any  rate  possible  that  child-bearing  is,  in  some  cases,  an  exciting  cause. 
In  three  cases  of  intermenstrual  pain,  where  pregnancy  occurred,    the    suf- 


134 


INTERMElSrSTETTAL    PAIN. 


fering   ceased   entirely   during  the   pregnancy   and   during   lacta- 
tion,   returning  on  the  reestablishment  of  menstruation. 

Bate  of  Pain. — The  data  on  this  point  are  not  so  full  as  could  be  wished; 
in  some  cases  the  statement  is  made  that  the  intermenstrual  pain  occurred  a 
certain  number  of  days  after  menstruation,  leaving  it  uncertain  whether  this 
means  after  the  beginning  or  the  end.  In  other  instances,  where  the  date  is  defi- 
nitely stated  to  be  after  the  end,  the  lenglh  of  the  period  is  not  mentioned,  and 
therefore  the  cases  cannot  be  compared  with  others  where  the  date  is  definitely 
stated  from  the  beginning.  The  value  of  the  cases  reported  by  Storer  (Boston 
Med,  and  Surg.  Jour.,  1900,  vol.  142,  p.  397),  which  are  by  far  the  largest 
number  given  in  any  one  instance,  is  somewhat  depreciated  for  this  reason. 
There  appears  to  be  no  doubt,  however,  that  intermenstrual  pain  occurs 
always  about  the  middle  of  the  intermenstrual  period,  and  ex- 
tends into  the  second  half  of  it.  In  nine  cases  the  date  of  the  pain 
was  given  as  "  midway  "  and  in  two  of  these,  which  were  in  my  own  practice, 
the  pain  was  so  exactly  between  the  periods  that  the  date  of  the  approach- 
ing one  could  be  foretold  from  the  day  upon  which  the  intermenstrual  pain 
appeared ;  that  is  to  say,  if  the  intermenstrual  attack  occurred  on  the  twelfth 
day  after  the  beginning  of  menstruation,  the  next  period  would  be  upon  the 
twenty-fourth  day.  The  following  record  taken  from  one  of  these  cases  illus- 
trates this  point: 

Menstruation December    1 

Intermenstrual  pain ,  .         "  10     Interval    9  days 

Menstruation "  19  "  9  " 

Intermenstrual  pain "  30  "  11  " 

Menstruation January  10  "  11  " 

Intermenstrual  pain "  21  "  11  " 

Menstruation February  1  "  11  " 

Intermenstrual  pain "  17  "  16  " 

Menstruation March  5  "  16  " 

In  another  case,  reported  by  Sorel  (Arch,  de  toe.  et  de  gynee.,  1873,  vol. 
14,  p.  269),  a  record  of  this  kind  was  kept,  extending  over  one  hundred  and 
forty-seven  periods,  and  although  the  intermenstrual  pain  did  not  occur  with 
the  absolute  exactness  shown  in  the  two  cases  just  mentioned,  it  varied  dis- 
tinctly according  to  the  date  of  the  menstrual  jDcriod  which  was  to  follow. 

Out  of  seventeen  cases  in  Avhich  the  intermenstrual  pain  was  dated  from 
the  beginning  of  the  preceding  menstruation  there  were  only  four  in  which  it 
was  stated  whether  menstruation  occurred  regidarly  every  twenty-eight  days, 
and  in  the  absence  of  this  information  it  is  impossible  to  estimate  the  relation 
of  the  pain  to  the  approaching  period.  Further  information  as  to  the  date 
of  intermenstrual  pain  in  relation  to  the  following  menstrual  period  is  much 
needed,  if  definite  conclusions  on  this  point  are  to  be  drawn.  All  that  can  be 
said  at  present  is  that  there  seems  good  reason  to  think  that  the  date  of 
intermenstrual  pain  is  associated  with  the  menstrual  period  fol- 
lowing the   pain   rather  than   that  preceding  it. 


RELATIONS    OF    INTEEMENSTETJAL    PAIN".  135 

Character  of  Pain. — 'No  special  form  of  pain  is  present.  In  some  cases  it 
is  noted  as  dull  and  in  about  an  equal  number  as  sharp;  in  only  a  few  cases 
was  it  ]Daroxysmal. 

Duration  of  Pain. — This  varies  from  a  few  days  up  to  the  whole  time  be- 
tween the  occurrence  of  the  pain  and  the  appearance  of  the  next  menstrual 
period.     In  the  majority  of  cases  it  lasts  three  to  four  days. 

Period  of  Time  which  the  Condition  May  Last. — This  also  varies.  In  one 
case  it  had  existed  only  a  few  months  when  the  patient  came  under  observation, 
while  in  another  it  had  lasted  twenty-two  years.  There  was  one  case  (Sorel, 
loc.  cit.)  where  it  began  with  the  first  menstruation  and  ceased  only  with  the 
menopause.      In   no    case    was    it    self-limited. 

Presence  and  Nature  of  Discharge. — In  thirty-nine  cases  out  of  sixty-four  a 
discharge  was  present.  Its  character  varied  greatly,  being  sometimes  a  simple 
leucorrhea,  sometimes  clear  and  watery,  and  sometimes  yellowish  and  irritat- 
ing. In  a  few  cases  it  was  bloody  or  blood-stained.  Attempts  have  been  made 
to  establish  a  relation  between  the  intermenstrual  pain  and  an  accompanying 
discharge,  but  there  seems  nothing  to  support .  such  an  idea.  The  fact  that 
in  three  out  of  six  cases  in  which  the  discharge  was  bloody  or  blood-stained 
there  was  an  endometritis,  a  polyp,  or  a  submucous  fibroid,  suggests  strongly 
that  in  cases  where  a  discharge  exists  it  is  connected  with  associated  lesions, 
and  not  directly  associated  with  the  intermenstrual  pain. 

Menstruation. — Intermenstrual  pain  does  not  seem  to  be  in  any  way  asso- 
ciated with  dysmenorrhea.  In  twenty-seven  cases  menstruation  was  noted  as 
painful,  while  in  twenty-three  it  was  painless.  In  the  remaining  cases  this 
point  was  not  recorded.  It  was  regular  in  a  good  many  more  cases  than  it  was 
irregular,  and  such  irregularity  as  occurred  was  in  the  line  of  anticipation.  In 
only  one  ease  was  it  noted  as  delayed.  There  was  a  tendency  to  excess  in 
fifteen  cases,  in  contrast  to  four  where  the  flow  was  scanty.  On  the  whole, 
however,  menstrual  variation  is  a  point  upon  which  information  is  lacking, 
and  special  attention  to  it  in  future  reports  is  desirable. 

Location  of  Pain. — In  a  large  proportion  of  cases  the  intermenstrual  pain 
was  situated,  roughly  speaking,  in  one  or  the  other  ovarian  region;  in  two  it 
was  in  both  ovarian  regions  at  the  same  time ;  while  in  five  it  was  in  the  right 
and  left  regions  alternately. 

Relation  between  Pain  and  Lesions  Found  on  Examination. — The  lesions 
observed  in  cases  of  intermenstrual  pain  are  somewhat  indefinite  in  character. 
In  a  good  many  cases  nothing  which  could  be  considered  a  lesion  was  present. 
In  those  where  lesions  or  abnormalities  existed  there  was  sometimes  a  relation 
between  its  nature  and  the  location  of  the  pain,  and  sometimes  none  whatever. 
Eor  instance,  out  of  twenty-four  cases  where  the  pain  was  situated  in  the  region 
of  the  ovary,  there  were  eight  in  which  there  was  tenderness  and  thickening  of 
the  ovary ;  one  of  hematoma  of  the  ovary ;  one  of  hydrosalpinx ;  and  one  of 
salpingitis.  There  were  also  five  cases  in  which  there  was  tenderness,  witli 
or  without  swelling,  in  the  broad  ligament  on  the  side  corresponding  to  the 


136  INTEEMENSTKUAL   PAIIS". 

pain.  Of  the  remaining  eight  cases  in  which  the  pain  was  situated  in  the 
ovarian  region,  no  deviation  from  normal  could  he  detected  on  examination. 
Of  eight  cases  where  the  pain  was  situated  in  the  hypogastrium,  one  was  a 
double  salpingitis  and  another  a  double  salpingo-ovaritis.  Of  the  remaining  six 
cases  of  hypogastric  pain,  one  was  recorded  as  normal,  four  were  displacements 
of  the  uterus,  and  the  remaining  case  was  a  large  fibroid.  Of  six  cases  where 
the  pain  was  stated  to  be  "  in  the  lower  abdomen,"  there  were  five  displace- 
ments, and  of  the  sixth  there  is  no  record.  In  all  the  remaining  cases  (thirty- 
four)  the  records  are  too  indefinite  to  be  available  for  use  as  statistics.  So 
far  as  they  go,  then,  these  results  would  seem  to  indicate  that  intermenstrual 
pain  is  not  necessarily  related  to  any  one  location,  but  rather  that  the  location 
is  determined  by  the  coexisting  abnormal  conditions. 

Treatment  and  its  Results. — The  results  of  treatment  in  intermenstrual  pain, 
so  far,  are  discouraging.  In  no  case  in  my  collection  has  it  shown  itself  self- 
limited,  while  in  one  case  (Sorel,  loc.  cit.)  it  lasted  throughout  the  whole  men- 
strual life.  Of  the  various  modes  of  treatment  adopted,  the  results  are  as  fol- 
lows: Dilatation  and  curettage  was  tried  in  eleven  cases,  entirely  with- 
out benefit,  except  in  one  instance  where  the  uterus  was  steamed  out  after  it, 
and  in  this  case  the  intermenstrual  pain  had  lasted  but  a  few  months.  Ova- 
rian, parotid,  and  thyroid  extracts  were  given  in  one  case  without  relief, 
but  in  another  the  thyroid  alone  was  followed  by  complete  recovery.  Elec- 
tricity over  the  ovarian  region  was  tried  in  four  cases,  two  of  which  were 
somewhat  improved,  while  the  other  two  derived  no  benefit  whatever.  Removal 
of  one  ovary  and  tube  was  tried  in  four  cases  where  the  localization  of 
pain  in  the  ovarian  region  seemed  to  indicate  it.  In  one  instance  the  pain 
was  relieved  for  a  period  of  eight  years,  and  in  another  it  has  now  been  absent 
for  six;  the  other  two  cases  were  entirely  unbenefited.  The  appendages 
were  removed  on  both  sides  in  five  cases,  two  of  which  were  among  the 
cases  mentioned  where  one  ovary  was  first  removed  without  benefit.  The  results 
in  one  instance  are  not  definitely  stated,  although,  judging  from  the  context, 
they  were  good ;  of  the  other  four  cases,  three  were  entirely  relieved  and  the 
other  not  at  all.  In  the  latter  instance,  however,  menstruation  continued  after 
the  operation  and  it  is  to  be  supposed  that  some  ovarian  tissue  remained  behind. 
Suspension  of  the  uterus  was  tried  in  three  cases  of  retro-displacement, 
with  complete  relief  in  one  case,  partial  relief  in  another,  and  none  at  all  in 
the  third. 

Partial  relief  was  also  obtained  in  three  cases  from  a  course  of  baths 
or  medicinal  waters  ;  in  one  case  frora  absolute  rest  in  bed  during 
the  attacks  of  pain,  with  straightening  of  the  uterus,  which  was  in  extreme  ante- 
flexion; and  in  one  case  from  the  use  of  a  Hodge  pessary  for  extreme 
anteflexion,  together  with  the  relief  of  a  coexisting  endometritis. 

Complete  relief  resulted  in  one  case  from  the  use  of  an  intra-uterine 
pessary  for  marked  anteflexion;  in  two  cases  from  six  months'  treat- 
ment for   endometritis,   nature  not  stated;  in  one  case  from  the   cure    of 


TREATMENT    AND    ITS    RESULTS.  137 

an  eroded  cervix;  and  in  one  from  rest  in  bed  during  the  attacks, 
with  support  of  the  uterus  by  tampons. 

All  that  can  be  determined  from  these  records  is  that  the  treatment  of 
coexisting  local  conditions  will  sometimes  relieve  intermenstrual  pain.  It 
should  always  be  tried,  together  with  attention  to  general  health  and  absolute 
rest  in  bed  during  the  attacks  of  pain.  In  regard  to  the  effect  of  the  removal 
of  one  ovary  and  tube,  the  results  are  too  scanty  to  warrant  an  opinion.  Re- 
moval of  both  appendages  can  probably  be  depended  upon  to  give  relief  as  a 
last  resort,  provided  the  pelvis  is  not  so  matted  with  adhesions  as  to  make  com- 
plete removal  impossible.  It  would  be  interesting  to  know  the  effect  of  induc- 
ing the  cessation  of  menstruation  by  removing  the  uterus  without  disturbing 
the  ovaries. 

I  give  here  three  illustrative  cases  from  my  own  records : 

Case  L — Mrs.  J.,  age  thirty,  November  13,  1894,  Case-book  V,  E"o.  113. 
This  patient  had  had  three  children,  the  youngest  of  whom  was  six  years  old 
at  the  time  she  consulted  me.  At  the  birth  of  her  second  child,  eight  years 
before,  the  perineum  was  badly  torn,  and  it  was  repaired  some  little  time  later. 
The  second  menstrual  period  after  the  operation  was  followed  by  the  intermen- 
strual pain,  which  had  occurred  regularly  since  then.  It  appeared  exactly 
between  each  two  menstrual  periods,  so  much  so  that  if  it  occurred  on  the 
thirteenth  day  from  the  beginning  of  menstruation,  the  following  menstrual 
period  was  on  the  twenty-sixth.  The  pain  was  situated  in  the  lower  abdomen 
and  lasted  from  six  to  twelve  hours.  Menstruation  was  regular,  painless,  and 
somewhat  free.  Just  before  the  intermenstrual  pain  began,  there  was  a  yel- 
lowish discharge  from  the  vagina,  which  lasted  until  the  pain  v/as  over.  On 
examination  of  the  pelvic  organs  the  uterus  was  found  anteflexed  and  the 
outlet  torn  through  the  sphincter.  The  ovaries  and  tubes  were  free  from  dis- 
ease. The  outlet  was  repaired  at  the  Johns  Hopkins  Hospital,  and  in  April, 
1907,  when  the  patient  was  last  heard  from,  she  w^as  still  suffering  from  the 
attacks  of  intermenstrual  pain,  although  for  the  last  three  or  four  years 
they  have  been  much  less  severe  than  formerly.  Her  general  health  is  much 
improved. 

Case  II.— Miss  W.,  age  thirty-nine,  October,  1897,  San.  'No.  512.  This 
patient  began  to  have  intermenstrual  pain  when  she  was  eighteen  years  old, 
four  years  after  menstruation  began.  The  pain  occurred  on  the  fourteenth  day 
after  the  beginning  of  menstruation.  It  was  situated  in  the  right  ovarian 
region  and  was  dull  in  character,  with  a  sense  of  weight.  Menstruation  was 
comparatively  painless,  a  little  frequent,  but  not  excessive.  There  was  a  con- 
stant leucorrhea,  which  was  increased  with  the  intermenstrual  attacks.  On 
examination  the  uterus  was  found  sharply  retroflexed.  Suspension  of  this  was 
followed  by  rapid  recovery  with  entire  relief  of  intermenstrual  pain  and  great 
improvement  of  general  condition.  The  patient  is  now  (1907)  in  excellent 
health. 

Case  III. — Miss  L.,  age  thirty-nine,  February,  1900,  San.  ISTos.  929  and 


138  INTEKMENSTEUAL    PAIN. 

1,226.  Intermenstrual  pain  began  a  year  before  she  consulted  me.  The  first 
attack  was  accompanied  by  a  rise  of  temperature  to  102°  E.  After  the  second 
attack  the  pain  in  the  pelvis  became  habitual,  with  exacerbations  at  the  inter- 
menstrual periods.  The  pain  was  situated  on  the  right  side  of  the  pelvis  with 
a  focus  of  gTcatest  intensity  over  the  region  of  the  right  ovary.  There  were 
occasional  paroxysms  of  extreme  pain  in  the  rectum,  extending  up  through  the 
right  side  of  the  pelvis.  Each  intermenstrual  attack  was  accompanied  by  head- 
ache, nausea,  and  nervous  exhaustion,  and  also  by  a  yellowish  irritating  dis- 
charge from  the  vagina,  which  was  sometimes  blood-stained.  Menstruation 
was  painful,  and  after  the  habitual  pain  set  in  became  profuse  and  frequent. 
Examination  showed  a  small  fibroid  uterus  and  considerable  tenderness  over  the 
base  of  the  right  broad  ligament,  exactly  corresponding  to  the  focus  of  the 
pain.  Dilatation  and  curettage  relieved  the  menorrhagia,  but  not  the  inter- 
menstrual pain.  The  various  gland  extracts  were  tried  without  benefit;  nor 
was  there  any  relief  from  electricity  or  vesication  over  the  right  ovarian  region. 
The  patient's  health  became  much  affected  from  the  incessant  pain;  she  lost 
nearly  thirty  pounds  and  had  a  haggard  appearance.  About  eighteen  months 
after  she  was  first  seen  the  right  ovary  and  tube  were  removed.  JSTothing 
abnormal  was  found  on  opening  the  abdomen,  and  the  appendages,  except  that 
they  were  swollen  and  congested,  presented  nothing  abnormal.  Relief  from 
pain  was  immediate  and  the  patient's  general  health  was  completely  reestab- 
lished. 

In  concluding  the  consideration  of  this  subject  I  may  say  that  a  study  of 
these  cases  leads  me  to  form  an  opinion  substantially  in  agreement  with  that 
of  Priestley,  namely,  that  intermenstrual  pain  is  definitely  associated  with  the 
physiological  changes  in  the  ovary  which  result  and  end  in  ovulation.  This 
view,  of  course,  makes  intermenstrual  pain  depend  upon  the  menstrual  period 
which  follows,  rather  than  upon  that  which  precedes  it,  although  it  is  usually 
associated  with  the  latter  in  recorded  cases.  But  the  fact  that  the  cases  in 
regard  to  which  I  have  fullest  data  all  show  a  definite  connection  with  the 
succeeding  menstruation  is  one  reason  for  my  opinion. 

Moreover,  the  other  opinions  expressed  as  to  the  cause  of  intermenstrual 
pain  do  not  seem  to  be  tenable.  Eor  instance,  it  has  been  claimed  that  it  is 
purely  a  nervous  manifestation  ;  but  if  this  w^ere  the  case,  the  removal  of 
both  appendages  would  in  all  probability  be  followed  by  nervous  manifestations 
in  some  other  region  of  the  body,  in  other  words,  by  a  change  of  neurosis, 
whereas  it  gives  complete  relief.  Eurthermore,  the  fact  that  the  absence  of 
ovulation  during  pregnancy  and  lactation  is  accompanied  by  a  cessation  of  inter- 
menstrual pain  supports  the  view  that  the  ovaries  are  directly  concerned  in  it. 
It  has  been  suggested  that  intermenstrual  pain  is  associated  with  fibroid 
tumors,  and  one  observer  claims  that  he  has  observed  a  swelling  of  fibroids 
during  an  attack  of  pain;  but  out  of  the  sixty-four  cases  just  considered  there 
were  only  six  of  fibroid  tumors.  Croom  (Edin.  Med.  Jour.,  1896,  vol.  1,  p. 
703)  agrees  with  Priestley  in  associating  intermenstrual  pain  with  ovulation. 


CON"CLUSIONS.  139 

but  "whereas  Priestley  connects  it  with  the  process  of  preparation  for  approach- 
ing ovulation  accompanied  by  menstruation,  Croom  believes  that  ovulation  takes 
place  at  the  time  of  intermenstrual  pain,  independent  of  menstruation.  It  is 
difficult  to  see,  in  this  case,  why  the  date  of  intermenstrual  pain  should  vary 
in  accordance  with  the  menstrual  period  following  it ;  moreover,  it  is  hardly 
possible  that  ovulation  would  take  place  regularly  between  two  menstrual 
periods  for  a  number  of  years,  and  even  through  the  whole  of  sexual  activity. 

Everything,  in  fact,  which  is  known  in  regard  to  intermenstrual  pain,  thus 
far,  seems  to  support  the  theory  which  associates  it  with  approaching  ovulation, 
taking  place  under  difficulties  which  are,  as  yet,  imperfectly  understood. 
Should  Frankel's  theory  as  to  the  relation  between  the  corpus  luteum  and 
menstruation  prove  correct,  some  light  may  be  incidentally  thrown  upon  the 
etiology  of  intermenstrual  suffering. 

Further  knowledge  of  the  subject  must  depend  upon  information  furnished 
by  a  large  number  of  records,  and  it  is  greatly  to  be  wished  that  all  cases  of 
intermenstrual  pain  should  be  carefully  observed  and  duly  reported.  I  am 
convinced  that  such  cases  are  much  more  numerous  than  they  are  supposed  to  be. 

The  points  which  should  be  noted  are:  (1)  Age  of  patient;  (2)  married  or 
single;  (3)  children  or  miscarriages;  (4)  date  at  which  intermenstrual  pain 
occurs,  with  special  reference  to  following  menstrual  period;  (5)  length  of  time 
pain  has  lasted;  (6)  location  of  pain;  (7)  duration  of  pain;  (8)  character  of 
pain;  (9)  age  at  which  pain  began;  (10)  condition  of  menstruation  as  regards 
pain,  regularity,  and  amount;  (11)  presence  and  nature  of  vaginal  discharge; 
(12)  results  of  pelvic  examination  or  of  abdominal  section;  (13)  treatment 
and  its  effect. 


CHAPTEE    VI. 

AMENORRHEA. 

(1)  Definition,  p.  140. 

(2)  Causes  of  primary  amenorrhea:  Maldevelopment,  p.  140;  atresia,  p.  142. 

(3)  Causes  of  secondary  amenorrhea:  Physiological,  p.  145;  mechanical,  p.  145;  constitutional, 

p.  146;  functional,  p.  149. 

(4)  Symptoms  and  diagnosis,  p.  150. 

(5)  Treatment:  Operation  for  imperforate  hymen,  p.  154;  galvanic  stem  pessaries,  p.  155;  elec- 

tricity, p.    155;  general  treatment,  p.  155;  treatment  for  chlorosis,  p.  155;  treatment  for 
functional  amenorrhea,  p.  159;  pituitary  amenorrhea,  p.  159;  emmenagogues,  p.  160. 

(6)  Vicarious  amenorrhea,  p.  160. 

Definition. — Amenorrliea,  or  absence  of  the  menstrual  flow,  is  a  symp- 
tomatic condition  accompanying  a  variety  of  affections.  It  may  be  broadly 
divided  into  two  classes :  one  in  which  menstruation  fails  to  appear  at  the  usual 
age,  and  one  in  which  it  ceases  after  it  has  been  established.  The  first  of  these 
is  known  as  primary  amenorrhea,  or  emansio  mensium,  and  the  second  as 
secondary    amenorrhea,    or  suppressio  mensium. 

CAUSES    OF    PRIMARY    AMENORRHEA. 

The  non-appearance  of  the  menstrual  flow  at  the  customary  age  is  always 
a  matter  for  serious  consideration.  There  are  two  different  conditions  from 
which  it  may  arise :  (1)  failure  of  development  (aplasia  or  hypoplasia) 
on  the  part  of  the  reproductive  organs;  (2)  atresia,  causing  obstruction  of  the 
genital  tract  of  some  sort.  The  second  class  is  not,  strictly  speaking,  an  amen- 
orrhea at  all,  but  a  retention  of  the  menstrual  fluid;  it  is  convenient,  how- 
ever, for  practical  purposes,  to  consider  such  cases  under  this  head. 

Maldevelopment. — Amenorrhea  due  to  failure  of  development  is  really  a 
rare  condition,  although  its  existence  is  often  assumed.  It  is  to  be  suspected 
in  the  case  of  a  young  girl  in  her  teens,  who  has  never  menstruated,  and  is 
easily  demonstrated  by  a  local  examination,  when  the  uterus  will  be  found  to 
have  a  characteristic  shape,  the  cervix  being  large  and  disproportionately  long, 
while  the  fundus  is  small  and  infantile  in  type.  The  following  case  is  of  this 
kind: 

Miss  McC,  age  nineteen  (San.  'No.  2396),  March,  1907.  The  patient  had 
had  complete  amenorrhea  for  three  years ;  before  this  date  menstruation  had 
been  regular  and  painless,  but  alwaj^s  scanty,  lasting  only  one  day.  The 
abdomen  was  opened  for  the  purpose  of  removing  the  appendix ;  the  right 
kidney  was  also  suspended.  On  examination  the  external  genitalia,  vagina, 
140 


OATTSES    OF    PEIMAEY    AMENORRHEA.  141 

and  cervix  uteri  were  found  normal,  wliile  tlie  uterus,  ovaries,  and  tubes  were 
infantile  in  type.  Tlie  ovaries  were  elongate,  white,  smooth,  and  sclerotic.  The 
right  ovary  measured  4  X  1|^  X  1^  cm.     No  corpus  luteum  was  present. 

In  cases  where  there  is  aplasia  of  both  uterus  and  ovaries  there  will  be  no 
attempt  at  ovulation,  and  therefore  no  symptoms  of  menstruation.  If,  on  the 
other  hand,  there  is  aplasia  of  the  uterus  while  the  ovaries  are  healthy  and 
functionally  active,  ovulation  will  take  place  as  usual  and  will  be  accompanied 
by  the  customary  menstrual  molimena,  .namely,  pelvic  pain,  headache,  and  nerv- 
ous manifestations  of  different  kinds,  recurring  at  intervals  of  about  four  weeks. 
As  the  uterus  is  incapable  of  responding,  no  relief  is  afforded  by  the  customary 
discharge,  and  the  patient's  sufferings  often  increase  until  her  general  health 
is  impaired. 

Cases  in  which  amenorrhea  is  associated  with  the  absence  of  one 
or  more  of  the  organs  of  generation  must  be  included  in  this  class, 
as  well  as  those  in  which  diseased  conditions  have  caused  sufficient 
degeneration  of  the  ovaries  to  destroy  their  function  before 
puberty.  A  case  of  this  kind,  in  which,  as  sometimes  happens,  the  patient 
was  to  all  appearance  perfectly  developed  physically,  is  given  by  W.  B.  Chase 
(Amer.  Jour.  Ohst.,  1898,  vol.  38,  p.  512). 

The  patient  was  a  married  woman,  twenty-four  years  old,  of  fine  physical 
development,  and  apparently  in  good  health,  although  she  had  never  men- 
struated. She  had  been  married  about  two  years  and  had  had  no  prospect  of 
children.  When  she  was  about  eighteen  she  began  to  have  attacks  of  pelvic 
pain,  accompanied  by  headache  and  nervous  excitability,  which  recurred  regu- 
larly every  four  weeks.  These  attacks  gradually  increased  in  severity  until 
her  sufferings,  especially  from  headaches,  became  so  severe  that  she  and  her 
family'  feared  insanity.  During  the  preceding  year  she  had  perceived  an 
abdominal  enlargement  and  could  clearly  define  a  tumor.  On  examination  the 
growth  was  easily  perceptible,  though  the  abdominal  walls  were  fat;  it  was  as 
large  as  a  five  months'  pregnancy.  All  the  rational  indications  pointed  to  a 
uterus  distended  with  menstrual  fluid  from  atresia  of  the  cervix,  but  the  uterus, 
which  was  pushed  up  under  the  pubes,  admitted  the  sound  to  the  usual  depth. 
As  the  patient  was  anxious  for  any  operation  which  offered  a  prospect  of  relief 
from  her  sufferings,  the  abdomen  was  opened,  when  the  pelvic  contents  were 
found  to  be  almost  completely  M^alled  off  by  peritoneal  adhesions,  although  the 
patient  was  never  conscious  of  having  had  peritonitis.  Two  tumors  were  found, 
one  a  multilocular  ovarian  cystoma  attached  to  a  smaller  growth  containing  a 
shrunken  ovary  the  size  of  a  large  lima  bean,  within  which  was  a  corpus  luteum. 
The  other  tumor  was  a  dermoid  cyst,  containing  hair  and  sebaceous  material, 
which  had  entirely  usurped  the  place  of  the  right  ovary.  ISTeither  of  the  uterine 
tubes  could  be  found.  It  was  plain  that  the  futile  attempts  at  ovulation  with 
its  attendant  suffering,  as  well  as  the  womanly  development,  had  been  occa- 
sioned by  the  presence  of  the  small  amount  of  ovarian  tissue  left  in  the 
cystoma. 


142 


AMEXOEEHEA. 


Atresia. — In  primary  amenorrhea  arising  from  atresia  of  the  genital  tract, 
the  ohstruction  may  exist  at  any  point,  that  is  to  say,  there  may  be  an  imper- 
forate hymen,  an  atresia  of  the  vagina,  or  (rarely)  an  atresia  of  the  cervix. 
In  such  cases  ovulation,  when  it  begins,  is  accompanied  by  menstruation,  and 
as  it  is  impossible  for  the  menstrual  flow  to  escape,  it  collects  behind  the  point 
of  atresia,  causing  distention  first  of  the  vagina,  then  of  the  uterus,  and  finally 
of  the  uterine  tubes.  The  customary  menstrual  molimena  are  present  and 
are  sometimes  accompanied  or  followed  by  bleeding  from  the  nose,  or  some 
other  mucous  membrane.     At  first  the  suifering  is  slight,  but  with  each  recur- 


FiG.   55. — A  Case  of  Atresia  of  the  Vagixa.     The  tip  of  the  index  finger  rests  at  the  vault  of  the 

vagina  showing  great  shortening. 

ring  period  it  increases  until  the  patient's  general  health  is,  in  some  cases, 
considerably  impaired. 

A  congenital  atresia,  with  absence  of  the  vagina  above  the  point  at 
which  the- tip  of  the  finger  rests,  is  shown  in  Figiire  55.  Figure  56  shows  the 
depth  to  which  a  shallow  vaginal  pocket  can  be  thrust  into  the  pelvis  by  blunt 
pressure  from  without.  This  patient  was  married  and  came  to  me  to  consult 
me  for  sterility.  Atresias  of  the  genital  tract  resulting  in  primary  amenor- 
rheas were  not  long  ago  considered  to  be  always  congenital,  except  in  the  rarest 
instances;  within  the  past  twenty-five  years,  however,  it  has  been  shown  that 
most  of  them  are  really  the  result  of  infectious  inflammatory  processes,  origi- 
nating for  the  most  part  in  the  acute  infectious  diseases,  especially  typhoid  and 
scarlet  fevers.    This  subject  is  more  fully  discussed  in  Chapter  X ;  I  cite  here, 


CAUSES    OF    PEIMAET   AMEISTOKEHEA. 


143 


however,  one  illustrative  case  related  by  L.  Pincus   {Monatsschr.  f.   Geh.  u. 
Gyn.,  1903,  vol.  17,  p.  751). 

A  young  girl,  seventeen  years  of  age,  who  had  never  menstruated,  had  been 
ill  for  some  weeks  with  a  mild  attack  of  typhoid  fever,  when  she  suddenly 


Fig.  56. — The  Same  Case  of  Atresia.     The  examiner  is  pushing  in  the  index  finger  and  showing 
the  potential  lengthening  of  the  vagina  under  strong  blunt  pressure  from  without. 

complained  of  severe  pain  over  the  symphysis.  An  area  of  resistance  about 
the  size  of  a  fist  had  already  been  discovered  in  that  locality.  The  pain  now 
complained  of  was  at  first  ascribed  to  an  effort  at  menstruation,  and  this  idea  was 
confirmed  by  the  patient's  having  a  discharge  of  thick,  brownish  blood  from  the 
genitalia  a  few  hours  later.  Shortly  after  this  occurred  she  became  worse,  and 
within  twelve  hours  she  died,  with  every  indication  of  peritonitis  due  to  per- 
foration. ISTo  autopsy  was  permitted,  but  an  examination  of  the  external  geni- 
talia, made  shortly  before  death,  showed  a  slight  tear  in  an  otherwise  closed 
hymen.  The  patient's  mother  said  that  her  daughter  had  been  in  the  habit  of 
having  attacks  of  abdominal  pain  resembling  colic  for  the  past  few  years ;  she 
also  stated  that  about  four  and  a  half  years  before  her  daughter  had  had  an 
attack  of  scarlet  fever,  and,  for  some  time  after  her  illness,  there  was  a 
discharge  from  the  vagina.  It  was  clear  that  the  scarlet  fever  had  set  up  an 
inflammatory  process  in  the  vagina  inducing  an   atresia   retrohymenalis, 


144 


AMENOKEHEA. 


with  imperforate  hymen,  and  this  resulted  by  degrees  in  hematocolpos, 
hematometra,  and  probably  hematosalpinx.  The  typhoid  fever  induced 
a  menstrual  flow,  or  an  atypical  metrorrhagia,  and  resulted  in  a  rupture  of  the 
tubes  and  of  the  closed  hymen. 

The  atresias  of  childhood  are,  for  the  most  part,  of  a  harmless  character, 
consisting  of  a  conglutination  of  the  labia  in  their  inner  surface.  This  cohesion 
is  continued  up  to  and  above  the  level  of  the  urethra,  where  there  is  an  open- 
ing, through  which  the  urine  escaj)es  freely  and  by  which  the  menstrual  dis- 


FiG.  57. — ^A  Conglutination  of  the  Labia  Minora  Just  Below  the  Clitoris  and  Above  the  Level 
OF  THE  Urethra.  This  is  quite  certainly  the  remains  of  an  extensive  adhesion  in  childhood,  of 
which  the  lower  part  has  been  ruptured,  wliile  the  tell-tale  bridge,  in  a  protected  situation  above, 
lingers  to  tell  the  story  of  the  original  condition. 


charge  may  escape,  later  on,  without  difficulty.  I  take  it  that  the  origin  of 
the  adhesion  of  the  nymphse  in  the  case  of  a  woman  who  had  borne  children 
(see  rig.  57)  is  susceptible  of  no  other  explanation.  Here  the  marital  rela- 
tion and  labor  have  destroyed  all  the  lower  part  of  the  cohesion,  leaving  only 
this  tell-tale  bridge  behind. 

J.  C.  ISTott  in  1843  called  attention  to  a  form  of  atresia  of  the  vagina  aris- 
ing in  young  infants  without  any  demonstrable  cause  {Ame7\  Jour.  Med.  Sci., 
1843,  vol.  5,  p.  246).  He  cites  two  cases  of  infants,  perfectly  normal  at  birth 
and  healthy  in  every  respect,  who  were  found  several  months  later  to  have 


CATTSES    OF    SECONDARY    AMENORRHEA.  145 

a  closure  of  tlie  vagina.  In  neither  case  was  there  any  history  of  inflam- 
mation; and  in  both  the  vagina  opened  spontaneously  in  the  course  of  a  few 
months. 

In  addition  to  these  two  distinct  classes  of  primary  amenorrhea,  every 
physician  is  familiar  with  cases  where  absence  of  menstruation  at  the  usual 
age  is  occasioned  by  general  backwardness  of  development,  arising 
from  constitutional  weakness  or  else  following  an  acute  disturbance  of  some 
kind.  These  cases  are  usually  recognizable  from  the  history,  as  well  as  from 
the  general  appearance  of  the  patient.  In  considering  this  group  it  must 
always  be  borne  in  mind  that  in  some  families  puberty  is  unusually  late,  with- 
out any  definable  reason  for  the  delay. 

CAUSES    OF    SECONDARY    AMENORRHEA. 

Secondary  or  acquired  arnenorrhea  may  arise  from  a  variety  of  causes, 
which  can  be  classified  as  physiological,  mechanical,  constitutional,  and,  what 
may  be  called  for  want  of  a  more  definite  name,  functional. 

Physiological  Amenorrhea. — The  great  physiological  cause  of  amenorrhea  is 
pregnancy,  a  fact  which  should  always  be  borne  in  mind;  for,  unless  it  is 
kept  first  on  the  list  of  possible  causes,  disastrous  mistakes  will  be  made,  espe- 
cially by  those  who  undertake  a  course  of  active  local  treatment.  Amenorrhea 
is  usual,  though  not  invariable,  during  lactation,  and  it  should  cease  with 
its  conclusion.  Prolonged  lactation,  however,  as  Vineberg  points  out, 
sometimes  results  in  atrophy  and  consequent  amenorrhea  which  persists  after 
lactation  is  over.  The  other  physiological  causes  of  amenorrhea  are  child- 
hood and  the  menopause.  During  childhood  the  whole  organism  is  under- 
going those  changes  which  eventually  express  themselves  in  ovulation;  while 
the  menopause  represents  the  physiological  relief  from  the  cyclic  changes  which 
follow  the  exhaustion  of  the  rej>roductive  system. 

Mechanical  Amenorrhea. — This  form  includes  cases  of  character  similar 
to  those  just  described  under  the  primary  amenorrhea  due  to  atresia.  Obstruc- 
tion of  the  genital  canal  may  occur  after  the  establishment  of  menstruation 
as  well  as  before  its  appearance,  resulting  in  like  manner  in  the  suppression 
of  the  flow.  Imperforate  hymen  is  the  only  atresia  of  the  genital  tract 
belonging  exclusively  to  the  class  of  primary  amenorrheas.  Obstruction  at 
points  above  the  hymen  may  result  from  an  infection,  although  the  fact  that 
infectious  diseases  are  so  much  more  frequent  in  childhood  makes  this  factor 
less  frequent  than  it  is  in  primary  amenorrhea.  There  are  other  causes,  how- 
ever, which  can  arise  only  after  sexual  maturity,  or  even  in  some  instances, 
after  parturition.  ISTot  a  few  cases  of  atresia  of  the  vagina  or  cervix  are  due  to 
necrosis  following  difficult  labor,  while  the  prolonged  or  inju- 
dicious use  of  pessaries  is  another  cause.  Jacobson  (8t.  Louis  Courier 
of  Med.,  1906,  vol.  34,  p.  58)  has  seen  several  cases  of  atresia  from  this  cause. 

Under  the  head  of  mechanical  amenorrhea  we  must  also  include  those  cases 
11 


146  AMEN-OREHEA. 

in  M-liicli  there  is  a  failure  in  devclopmeut  uf  tlic  genital  organs  sufficient  to 
render  menstruation  iiifre(|Tieiit  and  scanty,  apjiearing  in  sonie  instances  only 
a  few  times  during  the  whole  period  of  reproductive  activity,  although  it  is 
not  enough  to  suppress  the  function  altogether. 

It  may  also  he  caused  hy  hums,  scalds,  or  by  the  application  of  too  strong 
caustics  to  the  vagina  or  the  cervix.  Sir  J.  Y.  Simpson  has  reported  a  case 
in  which  atresia  of  the  cervix  was  occasioned  by  the  application  of  the  actual 
cautery  to  the  edges  of  a  vesico-vaginal  fistula,  caused  by  extensive  slough- 
ing of  the  upper  part  of  the  vagina  after  childbirth  ("  Diseases  of  Women," 
1872)  ;  and  Yeit  mentions  a  case  in  which  cicatrization  took  place  in  a  short 
time  from  the  application  to  the  vagina  of  a  tampon  soaked  in  a  fifty  per  cent 
solution  of  chloride  of  zinc. 

Constitutional  Amenorrhea. — This  form  is  found  in  almost  all  diseased  con- 
ditions, acute  or  chronic,  which  make  heavy  demands  upon  the  vital  forces. 
Such  a  repression  has  always  been  regarded  as  a  conservative  effort  on  the  part 
of  nature  to  preserve  the  patient's  strength ;  in  a  few  instances,  however,  it  has 
been  shown  that  the  morbid  condition  is  associated  with  an  atrophy  of  the 
genital  organs.  Thorn  (ZeitscJir.  f.  Geh.  u.  Gyn.,  1889,  vol.  16,  p.  57)  con- 
siders that  in  all  exhausting  diseases  there  is  a  temporary  atrophy  of  the  uterus 
and  ovaries  which  is  the  immediate  cause  of  the  amenorrhea,  and  he  cites  a 
number  of  cases  to  establish  his  point. 

Chlorosis. — The  commonest  constitutional  cause  of  amenorrhea  is  chlo- 
rosis. W.  Stephenson  in  1889  (Trans.  Obst.  Soc,  London,  1889,  voL  31,  p. 
101:)  called  attention  to  the  fact  that  this  disease  was  too  much  neglected  by 
gynecologists  and  the  same  accusation  might  be  made  to-day.  As  a  constitu- 
tional disorder,  chlorosis  falls  under  the  domain  of  general  medicine,  but,  owing 
to  the  disturbances  of  menstruation,  whether  amenorrhea  or  menorrhagia,  which 
are  among  its  distinguishing  features,  it  has  certainly  a  claim  upon  the  atten- 
tion of  the  gvnecologist. 

Chlorosis,  as  defined  by  Stengel  {Tweni.  Cent.  Med.,  vol.  7,  p.  326),  is 
"  primarily  a  blood  disease  dependent  upon  disturbances  of  the  hematopoetic 
system  " ;  "  not  a  disease  resulting  from  blood  destruction,  but  rather  from 
imperfect  hematogenesis."  The  ultimate  causes  of  the  imperfect  blood  devel- 
opment are  obscure.  The  disease  is  characterized  clinically  by  a  deficiency  in 
the  hemaglobin  of  the  red  blood  corpuscles  gTeatly  in  excess  of  the  diminution 
in  their  number:  a  peculiarity  first  pointed  out  by  Duncan  in  1S67.  In  the 
early  stage  of  chlorosis  the  number  of  red  corpuscles  may  be  hardly  below  nor- 
mal, even  though  the  hemoglobin  is  extremely  reduced,  but,  as  the  disease 
progresses,  the  number  of  the  corpuscles  diminishes,  while  the  striking  dispro- 
portion between  them  and  the  percentage  of  hemaglobin  persists.  The  reduc- 
tion in  the  hemoglobin,  as  Stengel  says,  is  primary,  the  reduction  in  the  cor- 
puscles secondary.  The  shape  of  the  red  corpuscles  is  often  changed,  and  the 
specific  gTavity  of  the  blood  is  usually  reduced  in  proportion  to  the  diminution 
of  the  hemaoiobin.     The  total  amount  of  blood  is  not  diminished  and  some 


CAUSES    OF    SECONDARY    AMEWOREHEA.  147 

observers  claim  that  it  is  increased.  No  special  changes  are  observed  in  the 
white  corpuscles  and  they  are  not  increased  as  in  other  forms  of  anemia. 

The  cansal  relation  between  chlorosis  and  disturbances  of  menstruation  is 
not  yet  understood.  Virchow  in  1872  showed  that  it  was  associated  with 
an  imperfect  development  of  the  heart  and  large  arteries  and  also,  in  many 
cases,  with  imperfect  development  of  the  sexual  organs.  He  considered,  that 
the  defective  development  of  the  circulatory  system  was  primary,  while  that  of 
the  sexual  organs  was  secondary.  Rokitansky,  on  the  other  hand,  believed 
that  chlorosis  was  necessarily  associated  with  imperfections  in  the  development 
of  the  sexual  organs.  Trankel  (Aixh.  f.  Gyn.,  1875,  vol.  7,  p.  465)  showed 
that  in  certain  cases  of  chlorosis  there  was  an  imperfect  development  of  the 
genital  organs  while  the  heart  and  other  organs  were  normal.  Stephenson  (loc. 
cit.)  insisted  that  the  imperfections  in  the  evolution  of  menstruation  observed 
in  chlorosis  constitute  as  constant  a  feature  in  the  disease  as  imperfections  in 
the  evolution  of  the  red  blood  corpuscles.  He  also  agreed  with  Virchow  in 
believing  that  a  special  diathesis  or  peculiarity  of  constitution  predisposing 
to  the  development  of  the  disease  was  present  in  most  cases. 

The  general  trend  of  opinion  in  the  present  day  is  to  the  effect  that  the 
amenorrhea  almost  always  present  in  chlorosis  is  the  result  of  the  impoverish- 
ment of  the  system,  as  in  simple  anemia.  It  is  difficult,  however,  to  reconcile 
this  view  with  the  intimate  relation  between  chlorosis  and  the  sexual  system. 
The  fact  that  the  disease  is  hardly  ever  met  with  in  childhood  or  after  the 
menopause  and  that  it  makes  its  appearance  at  periods  corresponding  to  epochs 
of  special  significance  in  the  sexual  life  of  women,  speak  strongly  in  favor 
of  a  direct  relation  between  it  and  the  reproductive  organs,  of  which  the  men- 
strual disturbance  is  but  the  outward  expression.  The  majority  of  cases  of 
chlorosis  occur  between  the  ages  of  fourteen  and  twenty-one,  which  is  the  time 
when  the  sexual  function  is  established ;  while  there  is  a  small  nundier  of 
cases  in  which  it  occurs  (or  recurs)  between  the  ages  of  twenty-four  and  thirty- 
five,  the  period  of  full  sexual  maturity  and  greatest  reproductive  activity. 

Complete  amenorrhea  is  not  common  in  chlorosis.  In  most  cases  the 
flow  appears  at  long  and  irregular  intervals  and  is  extremely  scanty.  In  sixty- 
five  cases  examined  by  Hayem,  menstruation  was  diminished  in  thirty-six, 
and  completely  suppressed  in  twenty-four,  while  in  four  it  was  normal  or  a 
little  increased.  In  a  few  rare  cases  chlorosis  is  accompanied  by  profuse  men- 
struation, and  both  Virchow  and  Frankel  have  pointed  out  that  in  such  cases 
the  ovaries  are  hypertrophic  instead  of  being  of  the  usual  infantile  type  (see 
Chap.  VII).  Contrary  to  expectation,  the  establishment  of  menstruation  is 
early  rather  than  late  in  chlorotic  patients. 

Constipation  is  so  often  a  marked  feature  in  chlorosis  that  Sir  Andrew 
Clark  believed  the  disease  was  really  due  to  a  copremia  from  absorption  of 
ptomaines  and  leucomaines  from  the  lower  intestine.  Emotional  and 
nervous  disturbances  are  sometimes  well  marked  and  some  writers  have 
held  the  disease  was  a  neurosis.      Disturbances   of   the   heart   and  cir- 


248  AMENORRTTEA. 

c Illation  leading  to  syncope,  breathlessness,  and,  possibly,  cyanosis,  are 
present. 

Tuberculosis. — A  frequent  cause  of  constitutional  auK'norrbea  is  tuber- 
culosis. The  disturbance  of  the  function  dates  from  the  earliest  stages  of 
the  disease,  and  the  patient  and  her  relatives  not  infrequently  regard  the  amen- 
orrhea as  the  cause  instead  of  the  result  of  the  tulDerculosis. 

Acute  diseases  of  all  kinds,  infectious  or  otherwise,  are  frequently 
accompanied  by  amenorrhea,  which  usually  lasts  through  convalescence  until 
health  is  re-established. 

Anemia,  both  primary  and  secondary,  is  usually  attended  by  suppression 
of  menstruation,  more  or  less  complete,  and  it  also  occurs  after  loss  of  blood 
from  any  cause,  especially  after  post-partum  hemorrhage,  when  the 
patient  may  not  menstruate  for  months  after  she  has  resumed  her  normal  habits 
of  life.  Malaria  is  an  occasional  cause  of  amenorrhea  and  should  always  he 
suspected  in  districts  where  it  prevails. 

Syphilis,  chronic  nephritis,  and  diabetes  mellitus  and  in- 
sipidus   are  all  occasionally  accompanied  by  amenorrhea. 

Chronic  digestive  disturbances  which  impair  nutrition  may  be 
associated  with  cessation  of  menstruation,  especially    gastric    ulcer. 

In  the  various  maladies  now  held  to  be  caused  by  disease  of 
the  glands  concerned  in  the  internal  secretions,  amenorrhea  is 
often  a  symptom,  but  whether  in  these  cases  it  is  simply  a  conservative  effect  or 
whether  there  is  some  direct  connection  between  these  disorders  and  the  sexual 
organs  is  not  yet  known.  Atrophy  of  the  uterus  is  often  noted  in  acromegaly 
according  to  Yeit.  Kleinwachter  has  shown  that  in  Basedow's  disease 
there  is  a  general  atrophy  of  the  genitalia  both  external  and  internal  (Zeitschr. 
f.  Geh.  u.  Gyn.,  1889,  vol.  16,  p.  14-4),  and  his  observations  have  been  con- 
firmed by  Theilhaber  (Arch.  f.  Gyn.,  1895,  voL  49,  p.  57). 

Obesity  is  an  occasional  cause  of  amenorrhea.  In  a  case  reported  by 
Lomer  (Centrhl.  f.  Gyn.,  1893,  vol.  IT,  p.  641)  the  patient  gained  fifty 
pounds  in  six  months  and  became  so  corpulent  that  she  could  hardly  move. 
She  complained  of  dizziness,  flushes  of  heat,  and  bleeding  at  the  nose.  Scari- 
fication and  blood-letting  at  the  external  os  uteri  relieved  the  symptoms. 
Whenever  a  young  woman  who  complains  of  amenorrhea  is  much  above  the 
average  weight  for  her  age  and  height,  esj^ecially  if  the  increase  coincides  with 
the  cessation  of  menstruation,  the  physician  will  do  wisely  to  turn  his  atten- 
tion to  the  vices  of  nutrition  which  are  responsible  for  the  obesity.  The  in- 
crease of  weight  is  considered  to  be  akin  to  that  often  seen  at  the  menopause, 
both  being  associated  with  a  repression  in  the  activity  of  the  uterus  and  ovaries. 
H.  C.  Coe  (Med.  Rev.  of  Revs.,  1906,  voL  12,  p.  506)  suggests  that  an 
amenorrhea  associated  with  obesity  may  be  nothing  but  an  early  symptom  of 
the  obscure  disorders  arising  from  disturbances  of  internal  secretions,  and  that 
the  recognition  of  this  fact  may  be  of  service  in  making  an  early  diagnosis. 
He  cites  an  illustrative  ease  in  which  amenorrhea,  accompanied  by  a  marked 


CAUSES    OF    SECONDARY    AMENOEKHEA.  149 

increase  in  weight,  preceded  acromegaly,  and  further  the  case  of  another  patient, 
under  treatment  for  Hodgkin's  disease,  where  irregular  and  scanty  menstrua- 
tion ending  in  complete  amenorrhea  lasting  for  some  time  preceded  the  glandu- 
lar enlargement.  There  was  a  little  anemia  present  in  the  last  case,  but  not 
enough  to  account  for  suppression  of  menstruation. 

Chronic  poisonings,  particularly  of  lead,  occasion  amenorrhea.  The 
habitual  use  of  opium  or  morphin  induces  in  time  a  more  or  less  com- 
plete cessation  of  menstruation.  The  use  of  alcohol  at  first  increases  the  men- 
strual flow,  but  eventually  it  may  check  it,  in  consequence  of  degenerative 
changes  in  the  tissues. 

Attention  has  been  called  by  W.  H.  Baldy  to  the  possibility  of  amenorrhea 
arising  from  the  uric  acid  diathesis  {Phil.  Med.  Summ.,  1903-4,  vol. 
25,  p.  239)  which  it  is  well  known  may  occasion  dysmenorrhea. 

Functional  Amenorrhea. — The  term  functional  is  used  to  define  that 
form  of  amenorrhea  in  which  a  patient  with  normal  generative  organs  and  in 
average  health,  ceases  to  menstruate  without  any  apparent  objective  cause,  local 
or  constitutionaL  Excitement,  shock,  or  sudden  fright  will  act  to 
cause  menstruation  to  be  delayed  or  missed  altogether.  I  have  known  a  case 
where  a  period  was  missed  from  no  other  apparent  cause  than  the  loss  of  sev- 
eral nights'  sleep  just  at  the  time  its  appearance  was  expected.  The  mere 
expectation  of  pregnancy  sometimes  acts  to  prevent  the  flow  in  the  case  of 
unmarried  women  who  have  exposed  themselves  to  the  risks  of  it.  It  often 
happens  in  such  cases  that  the  next  succeeding  period  appears  normally.  Again, 
an  intense  desire  for  children  may  focus  the  attention  upon  menstruation  and 
so  control  the  function  as  to  suppress  it  entirely,  leading  to  the  confident  hope 
that  pregnancy  has  taken  place.  Haultain  (Edin.  Med.  Jour.,  1900,  vol.  2, 
p.  339)  advances  the  idea  that  amenorrhea  of  the  kind  known  as  functional  is 
the  effect  of  an  impairment  of  controlling  nerve  centres. 

Another  form  of  amenorrhea  is  that  due  to  changes  of  climate.  It 
is  a  matter  of  common  observation  that  differences  of  climate  or  altitude  occa- 
sion disturbances  of  menstruation,  a  change  to  the  seashore  being  generally 
accompanied  by  an  increase  in  menstrual  flow,  while  that  to  a  higher  altitude 
may  be  attended  by  the  reverse.  Tilt  says  that  he  was  once  consulted  by  a 
lady,  who  had  shortly  before  established  a  large  boarding  school  for  girls  near 
London,  because  so  many  of  her  scholars  who  came  from  a  distance  suffered 
from  amenorrhea  that  she  feared  there  was  something  unhealthy  in  the  location. 
This  class  of  cases,  as  well  as  those  arising  from  shock,  fright,  or  excitement, 
are  explicable  on  Haultain's  theory.  Over-study  and  exhaustion  of  the 
nervous  system  are  also  frequent  causes  of  functional  amenorrhea.  Ex- 
posure to  cold  during  a  menstrual  period  with  a  consequent  sudden  stop- 
page of  the  flow,  which  may  or  may  not  return  next  time,  is  usually  classed  as 
a  functional  amenorrhea. 

Besides  the  causes  of  amenorrhea  cited,  there  are  certain  cases  in  which 
menstruation  occurs  at  irregular  intervals  for  which  no  definite  reason  can  be 


150 


AMENOEKHEA. 


assigned 


Could  we  follow  the  evolution  of  the  corpus  luteum  in  these  cases 
we  should  probably  be  able  to  understand  better  the  causal  nexus ;  the  first 
step  is  to  determine  whether  Frankel's  theory  as  to  the  relation  between  men- 
struation and  the  corpus  luteum  can  be  established. 


SYMPTOMS    AND    DIAGNOSIS. 

Amenorrhea  in  itself  is  only  a  symptom  common  to  a  variety  of  conditions, 
and  in  many  cases  where  it  is  the  sole  clue  the  physician  must  follow  the  vari- 
ous possible  causes  until  he  discovers  the  particular  condition  which  is  effective 
in  the  case  under  observation. 

In  a  case  of  primary  amenorrhea  the  first  question  to  be  considered  is 
whether  there  is  maldevelopment  of  the  pelvic  organs,  or  an  obstruction  at 
some  point  in  the  genital  tract,  or  whether  it  is  merely  an  expression  of  gen- 
eral backwardness  of  development.  The  doubt  can  be  set  at  rest  at  once  by  a 
local  examination,  but  the  conscientious  physician  will  hesitate  to  take  this 
step  in  the  young  and  unmarried  until  he  is  sure  it  is  indispensable.  The 
crucial  point  is  the  presence  or  absence  of  menstrual  molimena.  If  no  such 
symptoms  have  appeared  the  case  is  either  one  of  backwardness  of  development 
or  of  maldevelopment  (aplasia  of  the  reproductive  organs).  Under  these  cir- 
cumstances the  physician  is  justified,  if  the  girl  is  not  more  than  sixteen  or 
seventeen,  in  waiting,  in  the  hope  that  nature  and  a  little  attention  to  general 
hygiene  will  remove  the  difficulty. 

If  menstruation  does  not  appear  within  a  reasonable  time  a  bimanual  rectal 
and  abdominal  examination  may  always  be  made  under  anesthesia,  when,  if 


Fig.  58. — An  Elongate  Infantile  Ovary  with 
Puerile  Ttpe  of  Uterine  Body  Associated 
WITH  AN  Amenorrhea. 


the  case  is  one  of  faulty  development,  the  uterus  will  be  found  to  be  of  an 
infantile  type  with  a  small  undeveloped  fundus  and  a  disproportionately  large 
cervix,  while  the  ovaries  are  elongate,  smooth,  and  smaller  than  at  puberty 
(see  Fig.  58). 


SYMPTOMS    AND    DIAGNOSIS.  151 

If,  on  the  contrary,  the  patient  gives  a  history  of  recurrent  attacks  of  pel- 
vic pain,  headache,  dizziness,  and  nervons  excitability,  accompanied,  it  may  he, 
by  bleeding  from  the  nose  or  some  other  mucous  surface,  the  case  is  either 
one  of  maldevelopment  with  ovaries  functionally  active,  or  of  an  atresia  in 
the  genital  tract.  Here  an  examination  must  be  made  at  once  to  obviate  seri- 
ous consequences,  namely  the  formation  of  hematocolpos,  hematometra,  and 
hematosalpinx,  with  rupture  and  consequent  peritonitis. 

What  harm  may  arise  in  such  cases  from  neglect  is  shown  by  a  case  of 
Gebhard's  (Veit's  "  Handbuch  der  Gynakologie,"  1898,  vol.  3,  second  half, 
p.  60).  A  girl  of  seventeen  with  a  primary  amenorrhea  consulted  a  physician 
on  account  of  a  severe  colicky  pain  in  the  abdomen.  The  physician  made  no 
inquiry  into  the  menstrual  function  nor  did  he  suggest  any  local  examination. 
Inspection  of  the  abdomen  showed  a  painful  diffuse  tumor  above  the  symphysis 
extending  towards  the  right,  which  he  took  for  a  perityphilitic  exudate ;  for 
the  relief  of  this  he  made  an  incision  in  the  ileocecal  region  "  to  evacuate  the 
pus."  Instead  of  an  abscess  he  found  a  large  circumscribed  dark  red  swell- 
ing, looking  like  an  ovarian  tumor,  which  he  did  not  attempt  to  remove.  The 
patient  then  entered  the  clinic  where  the  diagnosis  was  apparent  on  the  first 
inspection  of  the  genitals  and  the  tumor  was  seen  to  be  a  large  hematocolpos 
due  to  an  atresia  of  the  hymen.     It  was  relieved  by  an  incision. 

Imperforate  hymen  is  at  once  .recognized  by  the  marked  bulging  tumor 
of  a  livid  or  dark  brown  color,  which  fluctuates  distinctly  upon  palpation,  pro- 
truding between  the  labia;  posteriorly  it  is  limited  by  the  perineum,  laterally 
by  the  inner  surface  of  the  labia,  and  anteriorly  it  reaches  to  the  posterior 
margin  of  the  urethra.  If  the  growth  is  sufficiently  large  to  fill  the  lower 
abdomen,  rising  as  high  as  the  umbilicus,  the  wave  of  fluctuation  is  readily 
transmitted  from  above  downward  to  the  tumor  at  the  vulva.  A  rectal 
examination  reveals  an  elongate  sac  filled  with  fluid,  occupying  the  position 
of  the  uterus  and  vagina  and  conforming  in  its  general  direction  to  the  axis 
of  the  pelvis.  Great  care  must  be  taken  in  the  examination  not  to  rupture 
the  thin  tubal  sacs  lest  a  fatal  hemorrhage  or  an  attack  of  peritonitis  should 
be  induced. 

Pregnancy  must  be  considered  in  every  case  of  amenorrhea,  coming  on 
in  women  who  have  menstruated  regularly  up  to  the  time  of  the  sudden  onset 
of  the  suppression,  if  the  patient  is  still  within  the  child-bearing  period.  It 
must  also  be  considered  in  atypical  cases  where  the  menstruation  has  been 
irregular.  The  examiner  does  not  insult  his  presumably  chaste  patient  by 
bearing  this  condition  in  mind  and  proceeding  at  the  first  step  he  takes  in  his 
diagnosis  to  exclude  it  from  the  category  of  possibilities  in  any  given  case. 
Pregnancy  is  diagnosed  by  recognizing  the  rotund  enlargement  of  the  uterus, 
sometimes  soft  and  boggy,  sometimes  firm,  but  almost  always  more  or  less 
globular.  In  some  cases,  it  feels  as  if  jointed  onto  the  cervix  which  may  be 
mistaken  for  the  uterus  itself,  while  the  body  above,  containing  the  fetus^ 
appears  to  be  a  tumor  attached  to  it  by  a  pedicle  (see  Fig.  59).     Ilegar  has 


152 


AMENOKEHEA. 


shown  that  softening  of  the  uterus  caused  bj  pregnancy  is  not  symmetrical; 
the  neck  retains  a  certain  resistance,  when  the  body  has  already  become  soft, 
and  the  upper  part,  which  contains  the  o\Tim,  is  tenser  than  the  lower  empty 
part  which  may  be  pressed  together  between  the  fingers  like  a  soft  membrane. 
This  sign  is  of  great  importance  in  the  early  diagnosis  of  pregnancy.     Anyone 


Fig.  59. — An  Early  Peegxanct  SHO"«axG  the  Globitlar  Enlargement  of  the  Uterine  Bodt. 
The  cervix  is  often  flexible  at  the  point  under  palpation  and  may  feel  like  an  organ  detached 
from  the  semi-fluctuant  mass  above. 


acquainted  with  the  extraordinary  relaxation  of  the  lower  segTuent  in  the  sec- 
ond or  third  months  will  avoid  the  not  uncommon  mistake  of  taking  the  cervix 
to  be  the  whole  uterus  and  the  pregnant  body  for  a  loosely  attached  tumor,  a 
pregnant  tube,  cyst  of  the  ovary,  etc. 

In  amenorrhea  of  women  over  forty,  there  is  always  a  possibility  of  the 
menopause.  Women  are  prone  to  assume  that  "the  change  of  life  is  work- 
ing "  as  early  as  thirty-five  or  even  earlier,  but  a  cessation  of  menstruation 
before  forty-one  or  two  is  rare  and  the  physician  should  accept  it  as  a  diag- 
nosis only  after  he  has  failed  to  find  any  other  cause  and  after  the  lapse  of 
some  months.  The  physiological  amenorrheas  of  childhood  and 
lactation   require  no  comment. 

Secondary  amenorrheas  of  the  mechanical  variety  are  easily  recognized 
by  the  existence  of  menstrual  molimena  without  a  regular  occurrence  of  the 
habitual  discharge,  and  examination  shows  the  nature  and  seat  of  the  obstruc- 
tion. There  are  certain  cases  of  secondary  amenorrhea,  caused  by  faulty  devel- 
opment, when  the  defects  are  not  sufficient  to  cause  primary  amenorrhea,  but 
menstruation  is  so  far  affected  that  it  takes  place  at  infrequent  intervals,  it  may 
be  only  a  few  times  in  the  whole  course  of  the  sexual  life.  The  history  of  such 
cases  is  very  suggestive  and  examination  makes  the  diagnosis  clear.  In  patients 
of  this  class  the  physical  development  as  well  as  the  general  health  is  sometimes 


SYMPTOMS    AND    DIAGNOSIS.  153 

excellent;  on  the  other  hand,  the  patient  may  be  poorly  developed  and  of  a 
manifestly  feeble  constitution. 

In  constitutional  amenorrhea  the  history  will  generally  supply  the 
clue  to  diagnosis.  Chlorosis  is  the  commonest  cause  and  here  the  appear- 
ance is  so  characteristic  as  to  suggest  it  at  once.  The  complexion  has  a  peculiar, 
transparent,  waxy,  greenish  hue,  from  which  the  disease  derives  its  name, 
unlike  that  of  other  forms  of  anemia.  The  conjunctivae  are  unnaturally  white 
and  clear  and  there  is  usually  a  disturbed  heart's  action,  manifested  in  short- 
ness of  breath,  palpitation,  and  great  fatigue  on  exertion.  When  the  disturb- 
ance of  the  circulation  is  marked,  there  is  apt  to  be  more  or  less  congestion  of 
the  terminal  blood  vessels  so  that  the  skin  has  a  muddy  cyanotic  look,  which 
to  some  extent  masks  the  typical  greenish  hue.  Menstruation  is  disturbed  by 
a  more  or  less  complete  amenorrhea;  the  flow  is  of  a  peculiar,  characteristic,, 
pinkish  color.  The  age  of  the  patient  is  a  point  which  must  be  considered, 
since  the  majority  of  cases  occur  between  fourteen  and  twenty-one,  with  a 
smaller  proportion  between  twenty-five  and  thirty. 

An  examination  of  the  blood  is  always  necessary  to  complete  the  diagnosis ; 
its  appearance  as  it  flows  from  the  body  is  characteristically  thin,  pale,  and 
watery.  The  hemaglobinometer  shows  that  the  percentage  of  hemaglobin  is  re- 
duced, while  the  hemacytometer  demonstrates  that  the  number  of  red  corpuscles 
is  not  diminished  proportionately.  In  a  series  of  ninety-four  cases  investigated 
by  Dr.  C.  E.  Simon,  the  average  hemoglobin  value  was  forty-two  and  a  half 
per  cent,  while  the  lowest  in  the  series  was  seventeen  and  a  half  per  cent. 
There  are  certain  rare  cases  of  great  reduction  in  the  number  of  red  corpuscles. 
One  is  mentioned  by  Hay  em,  where  only  937,360  were  counted,  and  three  by 
V,  Limbeck  in  which  the  red  corpuscles  were  1,750,000,  1,850,000,  and 
1,930,000  respectively. 

In  the  amenorrhea  of  tuberculosis,  patients  usually  complain  of  phthis- 
ical symptoms,  although  among  the  ignorant  classes  the  cough,  loss  of  weight, 
and  other  early  symptoms  of  phthisis  may  escape  the  recognition  of  the  patient 
and  her  family  and  she  may  complain  of  the  amenorrhea  and  nothing  more. 
The  suppression  of  menstruation  following  acute  diseases  offers  no  diffi- 
culty in  diagnosis.  In  some  chronic  conditions  the  whole  body  must  be 
carefully  examined,  as  well  as  the  lungs,  the  sputum,  and  the  blood. 

Obesity  associated  with  amenorrhea  suggests  some  vice  of  nutrition  which 
must  be  carefully  investigated,  and  the  suggestion  made  by  Coe  as  to  disease 
of  the  glands  employed  in  internal  secretion  deserves  to  be  borne  in  mind. 

TREATMENT. 

Primary  amenorrhea,  due  to  atresia  with  accumulated  menstrual 
secretions  above,  is  the  only  form  in  which  there  is  any  necessity  for  inmie- 
diate  action,  and  this  form  of  amenorrhea  is  not  really  a  true  amenorrhea 
at  all,  although  it  is  conveniently  considered  under  this  head.     If  the  general 


154  AMENOEKHEA. 

practitioner  has  convinced  himself  that  an  atresia  of  the  genital  tract  exists 
he  should  send  the  patient  without  loss  of  time  to  a  gynecologist.  A  form  of 
obstruction  which  may  claim  the  attention  of  the  general  practitioner  is  an 
imperforate  hymen.  It  is  better  to  refer  this  class  of  cases  as  well  as 
those  in  wliich  the  atresia  is  situated  higher  up  to  a  specialist,  but  as  circum- 
stances may  arise  in  which  the  general  practitioner  is  obliged  to  deal  with 
this  condition  himself  and  as  the  operation  itself  is  a  simple  one  if  performed 
with  extreme  antiseptic  precautions,  I  give  the  details  of  its  execution. 

Operation  for  Imperforate  Hymen. — Once  more  I  earnestly  insist 
upon  the  most  rigid  asepsis  at  every  step.  Lives  have  been  repeatedly  lost 
from  sepsis  coming  on  rapidly  after  opening  such  accumulations,  especially 
where  the  tubes  have  been  dilated.  The  blood  adhering  to  the  sac  and  the 
thin  walls,  together  with  the  sudden  change  in  the  pressure  in  the  blood  vessels, 
affords  material  for  sepsis,  as  well  as  a  ready  avenue  for  the  invasion  of  the 
neighboring  peritoneal  cavity  through  necrosis  of  the  thin  tubal  walls.  This 
danger  can  be  avoided,  however,  by  a  thorough  cleansing  of  the  field,  by  care 
against  infecting  the  tract  while  operating,  and  by  a  thorough  packing  with  iodo- 
form gauze  so  as  to  protect  the  field  for  some  days  after  the  operation.  After 
the  external  genitals  are  cleansed  and  the  operator  has  put  on  sterile  rubber 
gloves,  the  bulging  membrane  is  opened  by  a  crucial  incision,  dividing  it  into 
four  triangular  flaps  at  its  base.  The  thick  tarry  fluid  is  allowed  to  escape 
slowly  and  on  no  accoim.t  must  it  be  hastened  by  pressure  from  above,  for  fear 
of  rupture.  The  canal  is  then  washed  out  for  from  five  to  ten  minutes  with 
a  warm  saturated  boric  acid  solution  introduced  under  low  pressure  through  a 
long,  curved,  glass  douche  nozzle.  Pains  must  be  taken  to  empty  the  vaginal 
and  uterine  cavities  of  all  the  accumulated  blood.  An  abundance  of  iodoform 
and  boric  acid  powder  (1:T)  is  dusted  into  the  vagina  and  iodoform  gauze 
loosely  laid  is  packed  into  the  uterus  and  the  vagina  down  to  the  vaginal  outlet. 
The  urine  is  drawn,  the  powder  sprinkled  on  the  outside,  and  a  pad  of  sterilized 
cotton  is  laid  on  and  held  in  place  by  a  sterilized  T-bandage.  The  internal 
dressings  may  be  left  in  place  for  from  four  to  five  days  or  even  longer,  pro- 
vided everything  is  going  on  well  and  they  do  not  become  saturated  sooner. 
Whenever  they  are  wet  and  secretions  are  found  to  be  escaping  at  the  vulva 
they  must  be  changed  by  bringing  the  patient  to  the  edge  of  the  table  or  bed 
under  a  good  light,  withdrawing  the  pack  with  forceps  and  reinserting  it  by 
means  of  a  packer,  thus  using  every  precaution  to  avoid  infection  by  keeping 
the  gauze  from  all  contact  with  the  fingers,  the  buttocks,  etc.  By  this  method 
sepsis  is  avoided  and  the  one  great  danger  eliminated.  The  patient  should 
be  kept  in  bed  for  from  one  to  two  weeks. 

Cases  where  there  is  maldevelopment  of  the  reproductive  organs  should 
also  be  referred  to  a  gynecologist,  although  there  is  not  the  same  need  for 
immediate  action  as  in  the  case  of  an  obstruction  of  the  genital  tract.  When 
the  ovaries  are  able  to  perform  their  function  while  the  uterus  is  too  imper- 
fectly  developed  to  respond,   there  is  usually  no  relief  from  the  constantly 


TREATMENT.  155 

recurring  suffering  except  in  the  removal  of  the  ovaries,  but  this  should  only 
be  done  in  imperative  cases,  where  the  suffering  is  extreme.  Galvanic  stem 
pessaries  laid  within  the  uterus  have  been  recommended  for  puerile  organs  as 
well  as  for  those  cases  where  menstruation  occurs  at  infrequent,  long,  or  irregu- 
lar intervals,  but  without,  in  mj  opinion,  any  reasonable  claim.  Moreover,  as 
Herman  has  shown  {Med.  Press  and  Circ,  London,  1893,  vol.  55,  p.  269), 
they  often  irritate  the  endometrium,  as  shown  by  resulting  hemorrhage  and 
leucorrhea,  and  set  up  an  infection  which  may  spread  along  the  uterine  tubes 
to  the  peritoneum,  setting  up  a  fatal  peritonitis.  The  value  of  the  galvanic 
current  in  this  form  of  amenorrhea  has  been  much  praised  by  some  writers, 
the  negative  pole  being  applied  inside  the  uterus  (Apostoli).  I  am  not  pre- 
pared to  utter  a  sweeping  denial  of  these  claims  and  I  am  willing  to  concede 
that  it  is  perhaps  worth  trying  for  a  few  months.  The  cathode  shaped  like  a 
sound  is  introduced  into  the  uterus,  while  the  positive  pole,  a  long  dispersing 
electrode,  is  placed  on  the  abdomen.  Treatments  of  ten  minutes'  duration  are 
given  three  times  a  week ;  the  strength  of  the  current  should  be  twenty  to  thirty 
milliamperes. 

In  the  amenorrhea  of  young  girls,  whether  primary  or  secondary,  the  treat- 
ment should  first  of  all  be  directed  to  diverting  the  patient's  attention  from 
the  pelvic  organs  by  assuring  her  and  her  relatives  that  a  little  time  and  patience 
will  regulate  the  function.  Anemia,  often  present,  must  receive  consideration. 
Iron  is  beneficial  in  most  cases,  but  there  are  a  certain  number  in  which 
cod  liver  oil  appears  to  do  more  good.  E^ourishing  food  and  plenty 
of  fresh  air  and  exercise  are  essential  elements  in  the  treatment.  In 
schoolgirls  the  question  of  over-study  should  receive  earnest  attention.  No 
night  study  whatever  should  be  allowed,  and  the  amount  of  work  done  in 
school  hours  reduced  to  a  minimum.  In  any  case  where  the  amenorrhea  is 
obstinate  or  of  long  standing  and  the  patient's  health  is  manifestly  below 
normal,  it  is  the  wisest  plan  to  take  her  out  of  school  altogether  for  some 
months  or  a  year.  The  worst  that  can  result  from  such  a  course  is  the  delay 
of  a  year  in  graduation,  and  the  disappointment  attendant  on  this  is  a  trivial 
matter  compared  to  her  physical  welfare.  Great  attention  must  be  paid  to 
keeping  the  bowels  open,  as  constipation  is  closely  asso»ciated  with 
amenorrhea.  The  prescription  for  constipation  given  in  chlorosis  is  of  use 
in  all  forms  of  amenorrhea  (see  p.  143). 

Secondary  amenorrhea  due  to  constitutional  causes  must  be  treated  by 
attention  to  the  particular  cause  in  each  individual  case,  when  the  relief  of 
the  underlying  condition  will  almost  certainly  be  followed  by  the  re-establish- 
ment of  the  menstrual  function. 

In  chlorosis  the  great  indications  for  treatment,  as  Herman  has  said  (loc. 
cit.),  are  fresh  air,  light,  food,  iron,  and  laxatives,  to  which  might 
be  added  another  item  of  great  importance — intervals  of  rest.  It  is  a  matter 
of  common  observation  that  chlorosis  is  most  prevalent  in  unhealthy  surround- 
ings; indeed,  there  seems  much  to  favor  the  theory  of  Virchow  and  Stephen- 


J  56  AMENORKHEA. 

son  that  the  disease  depends  upon  a  constitutional  predisposition,  engendered 
by  damp,  darkness,  unhealthy  food,  and  general  want  of  hygiene.  Sunlight 
and  fresh  air  form  an  essential  part  of  the  treatment.  The  character  of 
the  food  must  be  nutritious,  and  as  Stanley  has  pointed  out  {Birmingliam 
Med.  Rev.,  1906,  vol.  59,  n.  s.,  p.  102)  the  diet  should  contain  a  large  pro- 
portion of  such  foods  and  vegetables  as  yield  a  considerable  amount  of  min- 
erals, especially  iron.  As  Stanley  remarks,  the  diet  of  working  girls,  among 
Avhom  chlorosis  is  most  prevalent,  sometimes  consists  largely  of  meat  and  is 
always  particularly  deficient  in  the  class  of  foods  just  mentioned.  Milk,  eggs, 
and  any  nutritious  easily  digested  foods  are  suitable,  and  it  must  be  remem- 
bered that  when  the  appetite  is  poor  and  capricious,  as  it  is  in  all  forms  of 
anemia,  especially  chlorosis,  any  article  of  food  not  absolutely  injurious  will 
be  of  service,  if  the  patient  has  a  fancy  for  it. 

Of  all  remedies  employed  in  the  treatment  of  chlorosis,  iron  has  always 
held  the  first  place,  although  exactly  how  it  works  is  not  known.  Carbonate 
of  iron  in  the  shape  of  Blaud's  pills,  is  the  preparation  considered  most 
efiicacious  by  authorities  in  general.     The  formula  is : 

I>   Ferri  sulph., 


.  ,    aa gr-   ij 

Potassi  carb., ; 

MuciL  trag.,  q.  s. 

M.     et  ft.  pil.  j.     Mitte  tales  100. 

It  is  best  to  begin  with  one  pill  three  times  daily,  after  each  meal,  and 
increase  the  dose  gradually  up  to  three.  Hay  em  recommends  the  oxylate 
of  iron,  as  less  irritating  to  the  stomach  than  the  carbonate,  in  pill  form, 
in  doses  of  one  to  five  grains.  The  tincture  of  the  chloride  of  iron 
also  gives  excellent  results,  in  doses  of  two  to  thirty  drops,  well  diluted  with 
water;  an  old  well-seasoned  preparation  should  be  used.  Reduced  iron  is 
another  useful  preparation,  in  pill  form,  the  dose  varying  from  one  to  five 
grains  after  each  meal.  Herman  {loc.  cit.)  recommends  the  ammonio- 
citrate  of  iron  combined  with  an  alkali  carbonate  and  made  up  with 
spirits  of  chloroform  to  make  it  palatable.     The  following  formula  is  effective : 

3^   Ferri  et  ammon.  cit 3j 

Potassi  carb gr.  xxiv 

Spts.    chlorof foj 

Aq.  dest.,  q.  s.  ad fovj 

M.      S.   One  dessert-spoonful  after  each  meal. 

When  the  stomach  is  too  irritable,  as  it  sometimes  is,  to  allow  of  iron 
being  given  by  the  mouth,  it  must  be  administered  hypodermically.  Dori, 
cited  by  Pratt  (N.  Y.  Med.  Times,  1905,  vol.  33,  p.  Y7),  considers  the 
ammonio-citrate  of  iron  best  for  hypodermic  use.  He  finds  that  jDatients 
are  able  to  tolerate  large  doses  of  iron  given  in  this  way  when  the  adminis- 
tration by  mouth  is  out  of  tlie  question.     The  daily  dose  is  three  centigrams 


TEEATMEFT.  157 

(about  one-lialf  of  a  grain)  dissolved  in  a  gramme  of  water  (about  half  a 
teaspoonful)   injected  into  the  interscapular  region. 

ISFext  to  iron,  arsenic  gives  the  best  results  in  the  treatment  of  chlorosis. 
It  may  be  given  as  Fowler's  solution  (liquor  potassi  arsenitis),  dose  two 
to  five  drops  three  times  a  day;  or  as  a  pill  in  the  form  of  arsenious  acid, 
dose  one-thirtieth  to  one-fiftieth  of  a  grain.  In  some  cases  it  is  best  to  give 
arsenic  hypodermically,  and  for  that  purpose  I  have  found  a  French  prepara- 
tion, the  cacodylate  de  sonde,  give  excellent  results. 

Manganese,  so  highly  recommended  in  the  treatment  of  all  forms  of 
amenorrhea,  is  considered  by  Stengel  to  be  useless  in  chlorosis.  If  it  is  tried 
it  should  be  in  the  form  of  the  dioxide,  dose  two  to  five  grains  in  pill 
three  times  a  day.  A  good  prescription  in  which  arsenic  and  manganese  are 
combined  with  iron  is  the  following: 

^   Ferri  sulph gr.  ij 

Acidi  arsen gr.  ^V 

Mangani    diox gr.  iij 

Mucil.  trag.,  q.  s. 

M.     et  ft.  pil.  j.     Mitte  tales  100. 

S.      One  pill  three  times  a  day. 

A  course  of    chalybeate    or    arseniate    waters    is  sometimes  useful. 

Forchheimer  finds  the  best  results  in  the  treatment  of  chlorosis  by  combining 
an  intestinal  antiseptic  with  a  blood  preparation.  He  gives  five  grains 
of  hydronaphtol  and  salol  before  each  meal  and  five  grains  of  hemo- 
gallol  after  it.  If  the  latter  preparation  cannot  be  obtained,  large  quan- 
tities of  beef  juice  may  be  substituted,  or  any  preparation  which  con- 
tains blood,  care  being  taken  to  make  sure  that  it  really  measures  up  to  its 
claims.  It  is  certain,  according  to  Pratt  (loc.  cit.)  that  in  some  cases  of 
chlorosis  antiseptics  succeed  where  iron  fails.  The  success  of  this  plan  of  treat- 
ment seems  to  agree  with  Clark's  theory  that  chlorosis  is  caused  by  the  absorp- 
tion of  poisonous  products,  ptomaines,  etc.,  from  the  large  intestine. 

The  constipation,  which  almost  always  accompanies  chlorosis,  requires 
constant  attention.  Salines  are  the  best  form  of  laxative,  and  if  anything 
stronger  is  required  to  start  the  bowels,  calomel  may  be  administered  in 
broken  doses  of  one-eighth  to  one-sixth  of  a  grain,  at  intervals  of  half  an  hour, 
until  one  grain  has  been  taken.  The  following  prescription  recommended  by 
Hart  and  Barbour  is  excellent  even  if  somewhat  bitter: 

^   Magnesii   sdlph 5j 

Quin.  sulph gr.   xxiv 

Acidi  sulph.  dil f 3ii j 

Aq.  ■  dest,  q.  s.  ad f ."^vj 

M.     S.   One  tablespoonful  three  times  daily. 

The  bitter  is  really  a  valuable  adjuvant  to  the  purge. 


158  AMENORRHHA. 

Gastric  symptoms  must  be  met  according  to  tlie  indications.  When 
there  is  an  excess  of  hydrochloric  acid,  hirge  quantities  of  an  alkali  may  be 
given  before  meals.  In  some  cases,  where  the  glands  of  the  stomach  are 
atrojDhied,  Pratt  (loc.  cit.)  recommends  stimulating  the  small  intestine  by 
the  administration  of  the  ferment  of  the  pancreas  or  by  papain.  The 
dose  of  pancreatin  is  five  to  fifteen  grains  in  powders,  while  that  of  papain 
is  two  to  five  grains  in  the  same  form. 

Vomiting,  according  to  Stengel  (loc.  cit.)  is  best  treated  by  minute  doses 
of  calomel  combined  with  a  local  sedative,  such  as  cocain,  one-fortieth 
to  one-twentieth  of  a  grain;  dilute  hydrocyanic  acid,  one  to  two  drops; 
creosote,  one-quarter  to  one-half  drop;  or  carbolic  acid,  one  grain.  An 
excellent  prescription  for  this  purpose  is  the  following: 

^   Hydrarg.  chlor.  mit gr.  j 

Acidi  carbol gr.  vj 

Bismuthi  sub-nit.,  q.  s. 

M.     et  ft.  pil.  no.  viii. 

S.       One  pill  every  hour  until  relieved. 

JSTervous  symptoms,  when  they  are  present,  must  be  treated  accord- 
ing to  the  indications.  In  cases  combined  with  chorea,  which  are  not  infre- 
quent, arsenic  is  the  best  remedy.  For  the  severe  headache  which 
sometimes  accompanies  chlorosis,  the  various  coal-tar  preparations  may  be 
tried,  or  the    bromides. 

Finally,  one  most  important  remedy  in  chlorosis  is  rest.  Hayem  insists 
strongly  upon  this  point,  as  well  as  Taylor,  cited  by  Pratt  (loc.  cit.),  who 
says  that  the  classical  treatment  of  chlorosis  with  iron  and  purgatives  is  not 
assisted,  but  rather  counteracted  by  the  accompanying  prescription  of  exer- 
cise. "  Against  fresh  air,"  he  says,  "  I  have  nothing  to  say,  as  long  as  it  does 
not  involve  exercise  either  by  walking  or  riding.  It  is,  of  course,  partly  a 
question  of  proportion;  the  worse  the  case,  the  more  absolute  should  be  the 
rest.  In  a  slighter  degree  of  anemia,  or  in  one  already  recovering,  carriage 
exercise  may  be  allowed,  while  in  the  severer  forms  the  patient  may  with 
advantage  be  kept  in  bed  entirely,  the  most  certain  means  of  keeping  her  abso- 
lutely at  rest.  An  intermediate  prescription  is  that  the  patient  shall  only  get 
up  for  three  or  four  hours  in  the  afternoon." 

Edgecombe  has  sho^^Ti  that  under  normal  conditions  there  is  a  fall  in  the 
percentage  of  hemaglobin  during  the  day  with  a  rise  at  night.  Moreover,  the 
daily  diminution  is  increased  by  exercise.  His  observations  were  made  upon 
healthy  persons,  but  they  are  significant  of  what  rest  may  do  in  building  up 
hemaglobin,  Hayem  has  shown  that  when  chlorotic  patients  are  allowed  to 
walk  about,  the  blood  pigment  present  in  the  urine  is  greatly  increased  over 
the  amount  present  during  rest.  It  is  safe  to  say  that  the  routine  prescription 
of  fresh  air  and  exercise  in  chlorosis  is  one  which  should  be  modified.  Fresh 
air  is  important,  but  active  exercise  should  be  proscribed.      In  well-marked 


TEEATMENT.  159 

cases  absolute  rest  in  bed  should  be  prescribed  until  there  is  a  decided  increase 
in  the  percentage  of  heiiiogl<»l)in.  After  this  point  is  reached,  the  patient  should 
have  passive  exercise  in  the  open  air,  with  massage.  In  milder  cases  it  is 
enough  to  insist  upon  rest  in  the  recumbent  position  for  several  hours  every 
day,  and  the  absence  of  active  exercise.  In  the  treatment  of  chlorosis  it  must 
always  be  remembered  that  relapses  are  frequent,  and  therefore  the  treatment 
should  always  be  kept  up  for  some  time  after  the  patient  is  apparently  restored 
to  health. 

In  amenorrhea  occurring  during  the  course  of  tuberculosis,  attention 
should  be  directed  to  the  tubercular  affection.  Should  the  primary  condition 
be  arrested  and  the  general  health  restored,  menstruation  will  return,  while 
if  the  disease  progresses,  the  absence  of  the  menstrual  flow  should  be  regarded 
as  a  benefit. 

The  amenorrhea  which  accompanies  or  follows  severe  illnesses  should 
also  be  looked  upon  as  a  blessing,  since  the  absence  of  the  menstrual  flow  is 
nature's  effort  to  conserve  strength.  'No  treatment  is  necessary  beyond  atten- 
tion to  the  general  health,  and  the  patient  and  her  relatives  can  be  assured 
that  with  the  return  of  health  the  function  will  almost  certainly  be  re-estab- 
lished. 

A  functional  amenorrhea,  as  a  rule,  requires  no  treatment.  In 
cases  where  it  arises  from  shock,  alarm,  or  nervous  disturbance,  the  physician 
can  only  counsel  patience  until  the  nervous  system  has  had  sufficient  time  to 
recover.  In  cases  where  there  is  a  sudden  stoppage  of  menstruation  from 
exposure  to  cold,  the  treatment  should  be  calculated  to  restore  the  circulation 
to  its  normal  rhythm,  for  the  causes  at  work  probably  act  mainly  through  the 
vaso-motor  system.  The  patient  should  have  a  hot  tub  or  hip  bath  and  be  put 
to  bed,  warmly  covered  up,  with  hot-water  bottles,  and  a  hot  poultice  over  the 
hypogastrium.  I  have  myself  cured  one  case  of  over  a  year's  standing  by 
feeding  large  amounts  of  the  fresh  corpus  luteum.  The  patient  sometimes 
suffers  from  attacks  of  headache,  dizziness,  and  flushes,  recurring  at  intervals 
corresponding  generallj^  to  the  expected  menstrual  periods.  In  such  cases  as 
these  the  discomfort  can  often  be  relieved  by  scarifying  the  cervix  until  a  few 
ounces  of  blood  have  been  removed.  W.  L.  Burrage  has  successfully  treated 
cases  of  this  kind  by  the  application  of  leeches  to  the  cervix. 

Pituitary  Amenorrhea. — It  seems  more  than  likely,  in  view  of  accu- 
mulating clinical  facts,  that  amenorrhea,  dysmenorrhea,  and  menorrhagia  are 
frequently  due  to  disturbances  in  the  function  of  the  internal  secretory  organs, 
notably  the  pituitary  body,  the  thyroid  gland,  and  the  suprarenal  capsules. 

The  normal  pituitary  gland  may  exercise  an  important  control  over  and 
stimulate  the  ovarian  function.  If  this  conjecture  is  correct,  then  a  lowered 
activity,  as  found  in  pituitary  tumors  and  cyst  cases,  would  explain  the  pro- 
duction of  a  peculiar  class  of  cases  of  amenorrhea  which  present  the  following 
well-defined  symptom  complex:  A  comparatively  young  woman  begins  to  have 
scanty  menstruation,  and  in  a  few  months'   time  the  flow  ceases  altogether, 


160  AMENOEEHEA. 

while  during  the  same  period  she  takes  on  flesh  to  a  remarkable  degree.  There 
is  complete  loss  of  sexual  desire,  she  has  a  polyuria  and  headaches. 

In  such  a  case  give  pituitary  extract  grs.  1^,  three  times  a  day.  If  there 
is  lowered  blood  pressure  combine  it  with  suprarenal  extract. 

Emmenagogues. — I  do  not  myself  recommend  the  class  of  medicines 
knoA^TQ.  as  emmenagogues.  Their  action  is  extremely  uncertain,  and  should 
menstruation  appear  while  one  of  them  .  is  in  course  of  administration,  its 
ai^pearance  is  probably  due  to  causes  apart  from  the  drug.  In  amenorrhea 
due  to  unsuspected  pregnancy,  the  use  of  emmenagogues  has  been  followed 
by  most  disastrous  consequences.  The  principal  remedies  falling  under  this 
head  are : 

Manganese. — This  is  best  given  in  the  form  of  dioxide,  two  to  five 
grains  three  times  daily  in  the  form  of  a  pill.  The  permanganate  of  potash 
may  be  substituted,  dose  one-half  to  one  grain  three  times  a  day,  also  in 
pill. 

Apiol  (Garden  parsley). — The  dose  of  this  remedy  is  three  to  six  minims, 
administered  in  capsules,  after  each  meal.  The  administration  should,  be  begun 
several  days  before  the  flow  is  expected. 

Aloes. — This  should  also  be  begun  several  days  before  menstruation  is 
due,  in  the  form  of  purified  aloes,  dose  one  gTain;  or  aloin,  one-half  of  a 
gTain,  both  in  pill  form  three  times  daily. 

There  is  one  other  variety  of  amenorrhea  which  cannot  be  included  under 
any  of  the  classes  just  discussed,  and  that  is  the  amenorrhea  due  to  the  super- 
involution  following  severe  labor.  It  is  fortunately  rare,  but  it  must 
always  be  borne  in  mind  whenever  a  persistent  amenorrhea  is  noted  after  labor. 
Nothing  can  be  done  to  relieve  it. 

VICARIOUS    MENSTRUATION. 

Vicarious  menstruation  is  a  term  used  to  describe  a  condition  in 
which  in  the  absence  of  the  regular  menstrual  flow  a  substitutive  hemorrhage 
occurs  from  some  other  part  of  the  body.  There  is  some  disagreement  among 
the  members  of  our  profession  as  to  whether  a  vicarious  menstruation  really 
exists,  some  persons  contending  that  the  cases  reported  will  not  bear  analysis 
(Wilks,  Brit.  Gyn.  Jour.,  1886-7,  vol.  2,  p.  177)  ;  others  maintaining  that 
there  is  a  sufficient  number  of  authentic  cases  to  establish  the  reality  of  its 
existence  (R.  Barnes,  ibid.,  p.  151). 

As  Withrow  has  pointed  out  (Amer.  Jour.  Ohst.,  1892,  vol.  25,  p.  164), 
this  disagreement  arises  partly  from  a  lack  of  exactness  as  to  definition. 
Menstruation  has  been  usually  defined  as  a  periodical  discharge  of  blood  and 
endometrial  debris  from  the  uterus,  and  if  the  presence  of  endometrial  debris 
is  considered  essential  to  the  definition,  a  discharge  from  any  other  organ  than 
the  uterus  cannot  constitute  menstruation,  therefore  under  such  a  definition 
vicarious  menstruation  does  not  exist.     It  has  been  suggested  as  more  appro- 


VICARIOUS    MENSTRUATION. 


161 


priate   that   the   term    vicarious     hemorrhage     should   be    substituted   for 
vicarious  menstruation. 

The  term,  as  used  here,  is  intended  to  signify  a  discharge  of  blood 
taking  place  from  an  organ  other  than  the  uterus,  at  intervals 
corresponding  in  a  general  way  to  those  existing  between  the 
menstrual  periods,  menstruation  being  at  the  same  time  wholly 
or  partially  suppressed.  Under  this  definition,  vicarious  menstruation 
is  of  two  different  kinds :  one  in  which  the  regular  menstrual  flow  takes  place 
as  usual  and  is  accompanied  by  hemorrhage  from  some  other  organ  (supple- 
mental) ;  another  in  which  the  menstrual  flow  is  absent  and  its  place  is  taken 
by  hemorrhage  elsewhere  (substitutional). 

The  nose  is  the  most  frequent  situation  for  vicarious  hemorrhage,  but 
there  is  hardly  a  mucous  surface  in  the  body  from  which  it  has  not  been 
observed  to  take  place:  the  stomach,  the  intestinal  tract,  the  lungs,  the 
bladder,  the  vagina,  the  eye,  the  ear,  the  tonsils,  and  the  gums  have 
each  in  turn  been  reported  as  the  seat  of  the  flow,  as  well  as  the  nipples 
and  the  umbilicus.  It  has  also  been  observed  to  take  place  from  the  sur- 
face of  old  cicatrices,  and,  in  a  few  rare  instances,  from  the  skin, 
representing,  it  may  be,  the  "  bloody  sweat "  long  classified  among  medical 
curiosities.  One  special  form  of  vicarious  hemorrhage  is  the  discharge 
of  blood  from  the  bowel  which  sometimes  takes  place  at  long 
intervals  after  operations  for  the  removal  of  the  sexual  organs, 
and  represents  the  absent  menstrual  periods.  A  discharge  of  this  kind  rarely 
continues  after  a  few  months. 

The  efficient  underlying  cause  of  vicarious  menstruation 
is  not  yet  understood.  It  is  manifestly  a  part  of  the  ovarian  function, 
probably  of  the  corpus  luteum  in  process  of  formation,  to  stimulate  a  vaso- 
motor congestion,  which  in  some  cases  is  general,  as  shown  by  the  throbbing 
full  feeling  in  the  head  accompanied  by  pain  before  the  appearance  of  the 
menstrual  flow;  and  when  the  blood  is  once  discharged  the  tension  elsewhere 
is  reduced.  We  do  not  know,  however,  by  what  cause  this  local  congestion 
followed  by  discharge  of  blood  from  the  uterus  is  determined.  If  the  possi- 
bility of  relief  through  the  natural  channels  is  taken  away,  the  efferent  impulse 
is  diverted  and  concentrates  itself  upon  the  spot  in  the  body  at  which  the 
vessels  can  be  most  readily  dilated  and  ruptured.  The  impulse  instead  of 
being  reflected  from  the  ovaries  back  to  the  uterus  is  reflected  to  whatever 
vascular  area  responds  most  readily  to  it.  The  reasons  for  this  selective  action 
in  a  given  case,  however,  are  obscure. 

Withrow  (loc.  cit.)  mentions  an  interesting  instance  of  heredity  in 
connection  with  vicarious  hemorrhage,  in  which  there  were  two  sisters,  neither 
of  whom  had  ever  menstruated,  although  their  genital  organs  were  normal. 
One  of  them  never  showed  any  signs  of  menstruation,  but  the  other  had  attacks 
of  epistaxis  occurring  at  intervals  which  corresponded  in  a  general  way  to 
what  should  have  been  menstrual  periods.  The  attacks  began  at  puberty  and 
12 


162  AMENOREHEA. 

continued  np  to  the  age  of  fortv-oiie.  A  niece  of  these  women,  tlie  danghter  of 
au  older  sister,  resembled  them  in  never  menstruating,  her  pelvic  organs,  like 
theirs,  being  normal.  She  also  had  attacks  of  epistaxis  at  intervals  of  about 
four  weeks  for  a  number  of  years,  the  bleeding  taking  place  always  at  night. 
All  of  the  women  were  married  and  all  remained  sterile. 

The  treatment  of  vicarious  menstruation  must  depend  upon  the 
nature  of  the  case.  The  causes  of  the  accompanying  amenorrhea  must  first  be 
ascertained  and,  if  possible,  removed,  for  when  menstruation  is  re-established, 
the  vicarious  hemorrhage  will,  in  all  probability,  cease.  Seeliginan  (Centrbl.  f. 
Gyn.,  1893,  vol.  17,  p.  G42)  advises  the  use  of  a  hot  douche  during  the  time 
supposed  to  correspond  to  the  intermenstrual  periods,  for  the  purpose  of  induc- 
ing the  menstrual  flow.  In  cases  where  liormal  menstruation  cannot  occur,  the 
vicarious  hemorrhage  is  often  a  safety-valve  which  it  is  not  well  to  shut  down. 
If  the  relief  from  the  vicarious  hemorrhage  is  not  sufficient  to  relieve  the  head- 
ache, flushing,  and  dizziness  it  is  sometimes  a  good  plan  to  scarify  and  deplete 
the  cervix.  In  rare  cases  the  vicarious  liemorrhage  is  so  profuse  as  to  require 
measures  for  its  control.  Under  these  circumstances  the  usual  remedies  for 
checking  hemorrhage  should  be  tried,  adapting  them  to  the  situation  from 
which  the  liemorrhage  proceeds.  The  application  of  ice  is  of  service,  and  where 
the  hemorrhage  is  from  the  stomach  Kiistner  recommends  gastric  lavage  with 
iced  water. 

In  exceptional  instances  radical  measures  are  indicated.  Webster  ("  Text- 
book of  Diseases  of  Women,"  1907,  p.  Ill)  mentions  two  cases  of  vicarious 
hemorrhage  under  his  care  in  which  he  was  obliged  to  remove  the  ovaries  (in 
both  instances  diseased)  because  life  was  endangered  by  the  repeated  hemor- 
rhages. He  does  not  state  the  situation  of  the  vicarious  hemorrhage.  Fischel 
(Prag.  med.  Wochenschr.,  1894,  'No.  12)  has  been  obliged  to  resort  to  the  same 
radical  measure  in  a  case  of  rudimentary  uterus  accompanied  by  vicarious  men- 
struation in  the  form  of  hematemesis. 


CHAPTEE    VII. 

MENORRHAGIA  AND   METRORRHAGIA.     EXTRA-UTERINE   PREGNANCY. 

(1)  Definition,  p.  163. 

(2)  Classification  of  forms  of  uterine  hemorrhage,  p.  164. 

(3)  Symptoms  and  Diagnosis,     (a)  Local  causes — Abortion,  p.  165;    polypi,  p.  166;    submu- 

cous myomata,  p.  168;  carcinoma  of  the  cervix,  p.  169;  carcinoma  of  the  fundus,  p. 
170;  sarcoma,  p.  172;  chorio-epithelioma,  p.  171;  retrodisplacements,  p.  172;  subinvo- 
lution of  uterus,  p.  172;  inversion  of  uterus,  p.  173;  acute  endometritis,  p.  174;  chronic 
endometritis,  p.  174;  hypertrophy  of  the  endometrium,  p.  175;  polypoid  endometritis, 
p.  175;  tuberculosis  of  the  endometrium,  p.  176;  cystic  ovaries,  p.  176;  pelvic  hemato- 
cele, p.  177;  corpus  luteum  cysts,  p.  177;  inflammation  of  the  tubes  and  ovaries,  p. 
177;  extra-uterine  pregnancy,  p.  177;  sclerosis  of  uterine  blood  vessels,  p.  177;  calci- 
fication of  uterine  blood  vessels,  p.  178;   (6)  Constitutional  and  vascular  causes,  p.  179. 

(4)  Diagnosis  of  uterine  hemorrhage  in  general,  p.  180. 

(5)  Treatment.     General  considerations,  p.  183.    Medicinal  measures,  p.  184.     Mechanical  meas- 

ures, p.  186.     Surgical  measures,  p.  188.     Constitutional  measures,  p.  193. 

(6)  Extra-uterine  pregnancy.      History,  p.  194.     Etiology,  p.  195.     Diagnosis,  p.  199.     Preg- 

nancy mistaken  for  extra-uterine  pregnancy,  p.  201.     Fibroid  tumors  mistaken  for  preg- 
nancy, p.  204.    Treatment,  p.  206. 

Definition. — Uterine  hemorrhage  is  of  two  kinds:  one,  which  is  periodical, 
that  is  to  say,  associated  with  the  normal  menstrual  flow,  is  for  this  reason 
called  monorrhagia  (monthly  bleeding)  ;  the  other,  occurring  at  irregular 
intervals  and  standing  in  no  manifest  relation  to  menstruation,  is  known  as 
metrorrhagia  (simply  uterine  bleeding).  In  some  cases  it  is  easy  to  use 
these  two  terms  with  discrimination,  while  in  others  it  is  impossible,  because 
the  conditions  co-exist.  Precisely  the  same  causes  often  give  rise  to  monor- 
rhagia and  to  metrorrhagia,  as,  for  example,  incomplete  abortion, 
cancer  of  the  cervix  or  of  the  body  of  the  uterus,  fibroid 
tumors,  and  extra-uterine  pregnancy.  It  is  plain,  therefore,  that 
it  is  not  always  possible  to  be  minutely  particular  in  the  classification  of  any 
particular  case  under  one  or  the  other  category,  and  that  the  terms  are  simply 
used  as  a  matter  of  general  convenience. 

There  is  no  difficulty  in  recognizing  a  case  of  uncomplicated  metror- 
rhagia, for  any  uterine  hemorrhage  occurring  at  times  other  than  the  regu- 
lar menstrual  periods  comes  under  this  head.  The  recognition  of  a  monor- 
rhagia is  more  difficult,  for  the  question  whether  the  menstrual  flow  is,  or 
is  not  excessive  must  be,  within  certain  limits,  a  personal  one.  The  normal 
habitual  discharge  of  a  plethoric  woman  would  be  a  serious  loss  to  another 
of  slight  build,  with  but  little  blood  to  spare.  Each  woman  soon  learns  her 
individual  norm  which  she  can  comfortably  bear,  and  realizes  that  if  it  is 
greatly  exceeded  for  several  periods  her  general  health  begins  to  sufl^er.  The 
common  method  of  estimating  the   amount  of  blood  lost  by  the  number  of 

163 


164  MENOKKHAGTA   AXD    :\rETT;OPvT;nArrIA.       extPvA-t:tert:n'e    TEEGNAITCT. 

pieces  of  i^iroteetive  gauze  or  ''  na})l-:ins  '■  used  is  a  fairly  j-clialile  ^vay  of 
e-auo-ins:  an  increase,  but  it  is  not  a  reliable  ffuide  as  to  tlie  absolute  amount. 
In  general  terms,  it  may  be  said  that  menorrhagia  exists  "wben  two  to  three 
times  the  usual  amount  of  blood  is  lost,  coming  away  in  spurts  or  gushes  of 
bright  red  color  or  accumulating  in  clots  in  the  vagina,  to  be  discharged  at 
intervals.  The  amount  of  Wood  lost  may  be  so  great  as  to  exhaust  the  patient 
greatly  and  even  endanger  life  and  it  is  always  an  important  point  in  the 
physician's  duty  to  decide  whether  the  loss  is  sufficient  to  impair  the  health. 
A  notable  characteristic  of  menorrhagia  is  the  fact  that  the  flow  is  greater  when 
the  patient  is  on  her  feet  and  moving  actively  about. 

Typical  menorrhagia,  then,  is  characterized  by  an  excessive 
flow  at  the  menstrual  period.  There  are  two  different  types  of  the 
condition  which  may  exist  separately  or  conjointly:  a  flow  which  is  excessive 
throughout  the  period,  and  one  which  is  unduly  prolonged  beyond  its  normal 
limits.  A  persistent  menorrhagia  of  either  t\'pe  reacts  upon  the  patient's  health, 
inducing  anemia,  shortness  of  breath,  and  general  debility. 

FORMS  AND  CAUSES  OF  MENORRHAGIA  AND  METRORRHAGIA. 

The  causes  of  uterine  hemorrhage  belong  im.der  three  classes :  Local,  con- 
stitutional, and  vascular. 

Local  causes,  due  to  conditions  present  within  the  pelvis,  are  the  following: 

Abortion, 

Polypi, 

Submucous  myomata, 

Carcinoma  of  the  cervix. 

Carcinoma  of  the  fundus, 

Sarcoma, 

Chorio-epithelioma, 

Ketrodisplacements  of  the  uterus. 

Subinvolution  of  the  uterus, 

Inversion  of  the  uterus, 

Acute  endometritis. 

Chronic  endometritis. 

Hypertrophy  of  the  endometrium, 

Polypoid  endometritis, 

Tuberculosis  of  the  endometrium, 

Cystic  ovaries. 

Pelvic  hematocele. 

Corpus  luteum  cysts. 

Inflammation  of  the  tubes  and  ovaries, 

Extra-uterine  pregTiancy, 

Sclerosis  or  atheroma  of  the  uterine  blood  vessels, 

Calcification  of  the  uterine  blood  vessels. 


LOCAL    CAUSES    OF    UTEIUNE    JlEMOlJiillAGE.  165 

Constitutional  Causes: 

Anemia,  especially  pernicious  anemia, 

Rheumatic  diathesis. 

Scurvy, 

Phthisis, 

Infectious  diseases. 

Vascular  Causes :     The  causes  lying  in  the  vascular  system  are  notably : 

Cardiac  disease  with  a  vascular  stasis,  especially  mitral  regurgitation. 
Hepatic  disease  with  a  portal  stasis,  as  in  cirrhosis. 

SYMPTOMS    AND    DIAGNOSIS. 

LOCAL    CAUSES. 

Abortion. — In  married  women  threatened  or  incomplete  abortion  must  al- 
ways be  suspected  as  the  cause  of  a  menorrhagia  until  its  existence  is  disproved ; 
only  in  this  way  will  mortifying  mistakes  be  avoided. 

Threatened  Abortion. — The  symptoms  indicating  a  threatened  abor- 
tion are,  pains  due  to  uterine  contraction  and  loss  of  blood. 
Loss  of  blood,  no  matter  how  slight,  in  the  early  months  of  pregnancy  should 
always  be  regarded  with  anxiety,  for  if  it  does  not  proceed  from  an  impend- 
ing miscarriage,  it  must  be  due  either  to  an  endometritis  or,  in  the  later 
months,  to  an  abnormal  placental  implantation.  When  due  to 
threatened  abortion  the  discharge  is  not  usually  profuse  at  first;  it  may 
be  of  a  dirty  brown  or  a  brownish  red  color,  or  it  may  consist  of  fresh  red 
blood  and  coagula.  This  premonitory  bleeding  may  hang  on  for  weeks,  or 
it  may  be  shortly  followed  by  the  complete  expulsion  of  the  ovum,  when  it 
ceases.  The  diagnosis  of  threatened  abortion  must  be  made  from 
the  history  of  a  missed  period  and  the  presence  of  some  uterine  enlargement, 
on  account  of  which  the  patient  herself  thinks  she  is  pregnant.  In  many  cases 
an  abortion  has  occurred  before  in  a  similar  manner. 

Incomplete  Abortion. — The  symptoms  of  incomplete  abortion  are 
a  complex  of  pain,  hemorrhage,  and,  it  may  be,  the  expulsion 
of  membranes.  One  characteristic  of  the  hemorrhage  often  present,  is  that 
it  comes  in  spurts  or  gushes  and  keeps  up  with  slight  intermissions  until  the 
miscarriage  is  complete.  It  sometimes  happens,  however,  that  the  abortion 
has  occurred  so  early  that  no  suspicion  of  pregnancy  has  arisen,  and  a  curet- 
tage undertaken  for  the  relief  of  the  hemorrhage  reveals  its  true  cause.  In 
a  recent  case  of  this  kind  in  my  own  practice  the  patient  complained  of  irregu- 
lar menstruation,  sometimes  profuse  and  sometimes  scanty.  For  about  three 
months  before  I  saw  her  the  flow  had  been  excessive  and  had  lasted  from  six 
to  seven  days.  Her  family  physician  ascribed  it  to  a  polyp,  seen  hanging  to 
the  uterus.      On  curetting  I  removed  a  large  amount  of  endometrial  debris 


166 


MENOEKHAGIA    AND    METROKKHAGIA.       EXTKA-UTEKINE    PEEGNANCY. 


which  macroscopicallj  resembled  carcinoma;  microscopical  examination,  how- 
ever, showed  syncytium  and  villi,  the  remains  of  an  incomplete  abortion.  Yet 
there  had  been  no  suspicion  of  pregnancy. 

In  doubtful  cases  the  diagnosis  of  incomplete  abortion  must 
always  rest  upon  the  microscopical  examination  of  curettings  from  the  endo- 
metrium. The  most  characteristic  appearance  in  the  often  abundant  tissue 
removed  is  little  villous  threads  and  dark  coagula  interspersed  through  the 
fleshy  masses.  Histologically,  a  glandular  hypertrophy  may  predominate, 
in  which  the  glands  are  dilated  and  convoluted,  with  little  tit-like  processes 
springing  from  their  lumina;  the  epithelium  is  somewhat  flattened  and  the 
stroma  of  the  mucosa  shows  marked  swelling  of  the  cells,  which  persists  for 
several  Aveeks  after  the  abortion.  AVhile  these  appearances  are  suggestive  of 
pregnancy,  a  positive  diagnosis  must  rest  upon  the  discovery  of 
villi.  In  the  early  months  these  will  be  found  to  show  two  layers  of  epi- 
thelial covering,  the  interior  of  which  is  made  up  of  cuboidal  cells,  while 
the  outer,  syncytial  layer,  appears  as  a  ribbon  of  protoplasm  with  nuclei 
distributed  through  it;  this  outer  layer  sends  out  protoplasmic  buds  which 
u         L  ^1       f^  form  new  villi  and  in  the  cen- 

Hemorrh-  placenta 

tre  of  these  buds  are  five  to 
forty  nuclei  forming  the  pla- 
cental giant  cell.  The  interior 
of  a  villus  is  composed  of 
mucoid  tissue  rich  in  blood 
vessels. 

A  Placental  Polyp. — A  pla- 
cental polyp  (see  Fig.  60)  is 
one  in  which,  after  the  expul- 
sion of  the  fetus,  the  long 
retained  fetal  elements  and 
blood  become  welded  together 
and  moulded  into  conformity 
with  the  uterine  cavity.  The 
placenta,  still  preserving  its 
attachment  to  the  uterine  wall, 
becomes  coated  with  layers  of 
old  coagula  until  it  hangs 
down  into  and  out  of  the  cer- 
vix, a  rounded,  pedunculate, 
polypoid  mass. 

Mucous  Polyp. — A  mucous  polyp  is  a  soft  growth,  produced  by  a  localized 
hyjjertropliy  of  the  uterine  mucosa,  which  becomes  pedunculate.  It  is  fre- 
quently associated  with  endometritis  and  with  fibroid  tumors.  Its  size  varies 
fvoni  that  of  a  pea  to  a  walnut  and  occasionally  it  is  larger.  Cervical 
polypi    (see  Fig.    61)    are  most  frequently   pedunculate   and   protrude   from 


Ext.  OS 


'yf^  pro^  ^' 


Fig.  60. — A  Placental  Polyp,  the  Prodxtct  op  an  In- 
complete Abortion,  formed  by  the  Contractions  of 
the  Uterus  acting  on  Hemorrhage  taking  place 
Slowly  at  the  Placental  Site.      (After  Bumm.) 


LOCAL    CAUSES    OF    UTEKINE    HEMOREIIAGE.  167 

the  external  os,  while  those  within  the  uterine  cavity  are  often  found 
near  the  tubal  ostia.  The  one  prominent  symptom  in  uterine  polypi  is 
hemorrhage,  which  is  sometimes  severe.  The  diagnosis  is  easily  made  when 
the  polyp  can  be  seen  hanging  into  the  vagina  or  just  within  the  os  uteri, 


Fig.  61. — A  Cervicai.  Polyp,  Appearing  as  a  Dark  Red  Mulberry  Mass  Just  Within  the  Cervix, 

AND  Causing  Hemorrhage. 

where  it  looks  like  a  smooth,  round,  fleshy  ball.  Sometimes  a  number  of  little 
red  polypi  depend  from  the  cervix.  A  microscopical  examination  shows  mucous 
membrane  with  uterine  glands ;  the  glands  are  mostly  normal,  but  when  they 
are  dilated  and  form  small  cysts,  the  epithelium  becomes  cuboidal  and  the 
cavities  contain  desquamative  epithelial  cells.  The  stroma,  especially  near 
the  tip  of  the  polyp,  often  shows  hemorrhage  and  edema.  When  no  polyp 
can  be  seen,  the  diagnosis  may  be  extremely  difficult  and  sometimes  can  be 
made  only  by  exclusion ;  that  is  to  say,  no  other  probable  cause  being  found 
for  a  protracted  hemorrhage  at  every  period,  persisting  for  months,  and  asso- 
ciated with  the  fact  that  the  uterus  is  not  markedly  enlarged,  warrants  the 
assmnption  that  the  trouble  is  due  either  to  a  polyp  or  a  small  submucous 
fibroid  tumor.  Occasionally,  a  polyp  can  be  removed  with  the  curette,  but, 
as  a  rule,  an  incision  into  the  uterus  is  necessary  to  discover  and  remove  it. 
Small  sessile  fibroid  OTowths  should  be  treated  in  the  same  manner. 


168 


2*rE:S^OKKIIAGIA    AIS^D    METRORRHAGIA.       EXTKA-UTERINE    PREGNANCY. 


Fig.  62. — ^A  Large  SuBMucotrs  Myoma  (&),  Solitahy  and 
Filling  the  Uterine  Cavity.     The  uterus  has  been  spht 
from  the  cervix  (a)  up   to  the   fundus  and  out  into  each 
■  cornu. 


Submucous  Myomata. — ]\Iost  mjomata  are  interstitial  in  the  beginning,  but 
it  often  happens  tliat  a  tumor,  beginning  in  this  manner,  is  carried  down  in 
the  course  of  its  development  into  the  uterine  cavity  where  it  is  attached  either 
by  a  broad  base  or  a  pedicle  of  varying  length  (see  Fig.  62).  The  two 
characteristic  symptoms  of  submucous  myomata  are  hemorrhage   and  pain. 

The  hemorrhage  is  often  ex- 
cessive and  reduces  the  pa- 
tient's strength  to  the  last 
degree.  The  pain  arises  from 
the  expulsive  efforts  of  the 
uterus  to  push  the  foreigii 
body  without  the  cervix,  and 
is  severe,  intermittent,  and 
expulsive  in  character  like 
that  of  labor.  Cases  some- 
times occur  in  which  the  pain 
is  slight  and  the  chief  symp- 
tom is  hemorrhage.  It  also 
happens  occasionally  that  a 
thin  serous  oozing  from  the 
tmnor  is  a  marked  symptom.  Direct  examination  shows  a  rounded  tumor  in 
the  vagina  or  just  inside  the  cervix.  By  passing  a  finger  around  it  on  all 
sides  the  tumor  will  be  found  to  be  smooth  and  to  have  a  pedicle  within  the 
uterus.  If  the  growth  is  still  retained  inside  the  uterus,  the  pedicle  may  be 
demonstrated  by  passing  a  sound  around  it  on  all  sides.  A  myoma  within  the 
uterus  has  the  characteristic  feel  of  a  ball  in  a  cup  and  it  may  sometimes  be 
rotated  so  as  to  show  that  it  has  a  narrow  pedicle  above.  A  myoma  sessile 
within  the  uterus  may  sometimes  be  diagnosed  without  difficulty  by  introduc- 
ing the  index  finger  through  the  cervix,  the  other  hand  being  used  to  make 
counter  pressure  through  the  abdominal  wall.  "Wlien  the  canal  is  too  small 
to  admit  the  finger,  a  sound  may  be  employed  instead.  By  noting  the  increased 
depth  of  the  uterine  cavity  and  tracing  its  irregularities  by  the  sound  moving 
within  it  and  by  palpation  per  rectum  and  per  abdomen  at  the  same  time,  an 
accurate  idea  may  be  obtained  of  the  size  and  location  of  thp  tumor.  Such  a 
fibroid  tumor  is  always  larger  than  a  mucous  polyp. 

To  differentiate  between  a  myoma  and  a  uterus  which  is  inverted, 
either  wholly  or  in  part,  the  peritoneal  surface  of  the  uterus  must  be  palpated 
by  the  rectum  when,  if  there  is  any  inversion,  the  corresponding  depression  on 
the  peritoneal  surface  will  be  felt.  Furthermore,  in  inversion  the  neck  of  the 
tumor  stops  short  inside  the  cervix  on  all  sides. 

A  submucous  myoma  is  sometimes  mistaken  for  cancer  of  the 
cervix,  which  is  not  surprising,  because  when  the  patient  suffers  for  a  long 
time  from  profuse  hemorrhage  she  acquires  a  cachectic  look  resembling  that 
of  cancer,  and,  moreover,  when  there  is  a  sloughing  myoma  it  gives  rise  to 


LOCAL    CAUSES    OF    UTEKINE    HEMOKRHAGE.  169 

frequent  fetid  discharges.  The  distinction  must  be  made  by  observing  the  loca- 
tion of  the  tumor  and  its  density  as  contrasted  with  the  friability  of  cancer. 
The  smaller  myomata  are  quite  smooth  on  the  surface  while  the  larger  are 
nodulated.  The  myoma  presents  a  distinct,  well-rounded  tumor,  contracted 
above  a  pedicle  which  enters  a  canal;  the  cancer,  on  the  other  hand,  is  a  tumor 
with  a  broad  attachment  to  the  cervix,  not  within  the  uterus,  and  often  only 
to  one  point.  The  diagnosis  between  a  small  submucous  myoma  within  the 
body  of  the  uterus,  which  cannot  be  felt,  and  a  cancer  of  the  fundus  may  be 
difficult,  but  if  the  endometrium  is  curetted  and  the  curettings  examined  micro- 
scopically, the  characteristic  changes  will  always  be  found,  if  the  growth  is 
cancerous  (see  Chap.  XXI,  p.  503).  As  a  rule,  these  submucous  and  peduncu- 
late myomata  are  not  single,  but  form  part  of  a  group  of  tumors  occupying  the 
body  of  the  uterus.  This  greatly  simplifies  the  diagnosis,  as  the  enlarged 
multinodular  uterus  is  early  recognized  as  myomatous,  the  presumptive  infer- 
ence being  that  the  particular  growth  which  is  giving  rise  to  the  hemorrhage 
is  of  the  same  nature. 

Carcinoma  of  the  Cervix. — From  the  age  of  thirty,  cancer  of  the  cervix 
must  always  be  considered  in  the  diagnosis  of  uterine  hemorrhage.  The  fre- 
quency with  which  the  disease  occurs  and  the  rapidity  of  its  advance  make  it 
important  to  recognize  it  at  the  earliest  possible  moment,  as  every  week  of 
delay  in  radical  treatment  (extirpation)  of  a  uterine  cancer  is  precious  time 
lost.  It  is  in  this  class  of  cases  that  the  policy  of  delay  can  too  often  be 
justly  laid  at  the  door  of  the  general  practitioner  by  his  fellow  specialist  as 
a  fault  which  makes  him  responsible  year  by  year  for  the  loss  of  many  lives. 
It  is  of  vital  importance  that  the  general  practitioner  should  recognize  the 
fact  that  anemia  and  cachexia  are  only  present  in  the  last  stages 
of  the  disease  and  that  pain  does  not  usually  appear  until  it 
has  progressed  beyond  the  cervix.  An  operation,  to  be  successful, 
must  be  performed  before  the  appearance  of  these  signs,  and,  as  a  rule,  it 
is  the  general  practitioner  who  sees  the  case  while  there  is  still  time  to 
save  life. 

Cancer  of  the  cervix  is  extremely  rare  in  women  who  have  not  borne 
children.  Menstruation  is  usually  regular  up  to  the  time  the  cancer  begins 
and  may  or  may  not  be  affected  by  it.  The  symptoms  of  carcinoma,  whether 
of  the  body  or  of  the  cervix,  are  hemorrhage,  watery,  foul  dis- 
charges, pain,  emaciation,  and  cachexia.  Watery  discharges  and 
hemorrhage  are  the  earliest  and  most  marked  symptoms,  although  the  latter 
may  be  absent  altogether.  The  hemorrhages  occur  at  other  times  than  the 
regular  periods  and  vary  in  frequency,  occurring  at  intervals  of  a  few  weeks 
to  several  months.  A  watery  discharge  is  often  an  earlier  symptom 
than  the  hemorrhage ;  it  may  irritate  the  external  genitalia  and,  as  the  disease 
advances,  it  becomes  purulent  and  malodorous.  Pain  is  not,  as  a  rule,  present 
until  the  disease  has  advanced  beyond  the  cervix ;  some  patients,  however, 
complain  of   cramp-like    pain   of   the   uterus   or  of  frequent   backache 


170  MEXOEKIIAGIA    AND    METKOKEHAGIA,       EXTKA-UTEKIXE    PKEGNAKCY. 

in  the  early  stages.  As  the  disease  progTesses,  the  gTOwth  presses  upon  the 
nerve  trunks,  and  the  pain  is  no  longer  limited  to  the  pelvis,  but  extends  to 
the  thighs,  knees,  and  doT\Ti  the  legs.  In  the  early  stages  and  often  np  to  a 
late  period,  the  patient  looks  well,  keeps  her  usual  weight,  and  is  not  at  all 
anemic;  in  all  but  a  few  eases,  however,  the  later  stages  are  accompanied  by 
great  emaciation,  anemia,  and  that  peculiar  unhealthy  pallor 
of  the  skin  characteristic  of  malignant  disease. 

A  vaginal  examination  in  the  early  stages  of  cervical  carcinoma 
shows  the  cervix  to  be  slightly  enlarged,  firm,  and  glazed  in 
appearance,  while  a  few  fine  finger-like  processes  may  project  from  the 
surface.  The  examining  finger  is  often  covered  with  blood  when  withdrawn. 
In  more  advanced  cases  the  upjDcr  part  of  the  vagina  is  filled  with  a  friable 
cauliflower -like  growth,  which  breaks  down  on  touch.  On  tracing  this 
upward  it  will  be  found  to  spring,  as  a  rule,  from  one  of  the  cervical  lips. 
It  is  at  this  stage  of  the  disease,  while  it  is  still  limited  to  the  cervix,  that 
the  diagnosis  is  a  matter  of  such  vital  importance,  for  the  results  of  operation 
performed  during  this  period,  reported  during  the  last  few  years,  are  most 
encouraging,  and  seem  to  indicate  plainly  that  ultimate  recovery  may  be  looked 
for  in  a  good  many  cases,  if  operative  interference  is  not  delayed.  As  cervical 
cancer  progTesses,  the  gTOwth  breaks  down;  the  cervical  lips  are  enlarged  and 
present  a  ragged  uneven  surface  extending  over  a  more  or  less  extensive  area 
at  the  vaginal  vault.  The  floor  of  the  eaten-out  area  is  very  hard,  but  small 
pieces  break  off  under  a  little  pressure  made  by  the  finger.  In  later  stages  all 
traces  of  the  cervix  disappear  and  the  vaginal  vault  is  occupied  by  a  small, 
puckered,  ulcerated,  hard,  nodular  area  covered  by  a  necrotic  brown  or  greenish 
slough. 

Carcinoma  of  the  Fundus. — Cancer  of  the  body  of  the  uterus  is  a  disease 
of  women  over  forty  and  usually  over  forty-five.,  The  uterus  is  commonly 
enlarged,  although  not  always,  and  the  cervix  is  hardly  ever  involved.  The 
hemorrhage  is  here  painless  and  persistent,  lasting  ten  days  or  longer,  and 
the  discharge  is  apt  to  be  dark  and  often  watery  as  well.  It  is  odorous  only 
in  the  later  stages.  An  atypical  fiow,  coming  on  in  a  woman  who  has  passed 
the  menopause  and  whose  uterus  is  not  markedly  enlarged  or  nodular,  as  in 
a  fibroid  uterus,  ought  always  to  arouse  more  than  a  suspicion  of  cancer  of 
the  body.  The  early  diagnosis  of  cancer  of  the  fundus  must  depend  entirely 
upon  the  microscopical  examination  of  the  scrapings  from  the  endometrium. 
Whenever  there  is  the  slightest  reason  to  suspect  the  existence  of  the  disease, 
the  uterus  must  be  curetted  without  loss  of  time  and  the  curettings  carefully 
examined  (see  Chap.  XXI,  p.  503). 

I  would  repeat  that  in  the  early  stages  of  either  form  of  uterine  carcinoma., 
a  positive  diagnosis  can  be  made  only  froui  a  uiicroscopical  examination  of 
the  curettings  from  the  uterine  lining. 

Sarcoma. — Sarcoma  of  the  uterus,  like  carcinoma,  may  occur  at  either  the 
cervix   or  the   fundus.     The  symptoms  are  much  the  same  as  those  observed 


LOCAL    CAUSES    OF    UTEKIJSTE    HEMOEBHAGE,  ^71 

in  carcinoma;  namely,  hemorrhage,  watery,  foul  discharges,  and 
pain,  together  with  more  or  less  cachexia  in  appearance.  Examina- 
tion of  the  scrapings  from  the  endometrium  will  show  the  characteristic  appear- 
ance of  sarcoma  if  it  is  present.  There  is  a  peculiar  form  of  cervical  sarcoma 
known  as  botryoidal,  or  grape-like,  in  which  the  vagina  is  filled  with  masses 
of  vesicular  bodies,  made  up  of  rapidly  growing  nodules,  each  with  its  own 
little  vesicular  pedicle.  Only  a  few  cases  of  this  disease  have  been  reported; 
I  have  myself  seen  but  one,  many  years  ago,  in  which,  not  recognizing  the 
condition,  I  amputated  the  mass  at  the  cervix.  The  operation  was  followed 
by  a  rapid  recurrence  and  the  invasion  of  all  the  surrounding  tissues.  Another 
form  of  sarcoma  appears  as  deep-red  or  bluish  masses  involving  the  vagina  as 
well  as  the  cervix,  which  once  seen  can  never  be  forgotten. 

Chorio-epithelioma. — Chorio-epithelioma  or  deciduoma  malignum, 
is  a  new  growth  developing  after  a  normal  pregnancy,  an  abortion, 
or  the  expulsion  of  a  hydatidiform  mole.  It  has  sometimes  been 
known  to  occur  before  the  mole  was  expelled.  Whenever  a  patient  gives  a 
history  of  monorrhagia  following  recovery  from  a  labor,  a  miscarriage,  or 
especially  the  expulsion  of  a  mole,  and  examination  shows  that  the  uterus  is 
enlarged,  the  presence  of  chorio-epithelioma  must  be  suspected.  The  diagnosis 
can  be  made  with  certainty  only  by  examination  of  the  curettings  from  the 
endometrium,  and  it  must  be  remembered  that  in  curettage  for  chorio- 
epithelioma  it  is  easy  to  get  a  piece  of  the  uterine  wall  which  will  suggest 
a  fibroid  tumor.  Histologically,  the  tumor  is  composed  of  blood  spaces 
surrounded  by  the  elements  of  the  growth,  derived  from  both  layers  of  the 
fetal  ectoderm  and  presenting  in  an  exaggerated  manner  the  peculiar  charac- 
teristics of  these  cell  elements.  The  syncytial  masses  present  are  multinuclear, 
with  dark  staining  nuclei  and  numerous  vacuoles.  The  elements  from  the 
Langerhans'  layer  are  large  cells  with  clear  protoplasm  and  vesical  nuclei  in 
which  karyokinetic  figures  are  frequently  visible.  These  are  especially  percep- 
tible about  the  margins  of  the  growth  and  invade  the  surrounding  muscular 
tissue.  The  first  evidence  of  growth  may  be  found  in  metastases  into  the 
vaginal  walls  or  into  other  organs,  and  in  some  instances  the  entire  growth 
disappears.  It  is  not  always  easy,  however,  to  distinguish  chorio-epithelioma 
from  a  benign  hydatidiform  mole  by  means  of  the  curettings,  and  all  the 
clinical  facts  must  be  weighed,  together  with  the  histological  findings,  in  order 
to  differentiate  between  the  two  conditions.  Profuse  uterine  hemorrhage 
beginning  a  few  weeks  (six  on  an  average)  after  the  termination  of  pregnancy 
and  leading  to  profound  anemia  is  strongly  suggestive  of  deciduoma.  In  some 
instances  the  interval  of  development  has  been  as  much  as  a  year  after  the 
previous  pregnancy;  where  a  still  longer  time  has  elapsed,  the  question  must 
be  considered  whether  a  pregnancy  has  not  occurred  of  which  the  patient  was 
Ignorant.  A  fetid,  watery  discharge  is  sometimes  present;  pain  has 
been  noted  in  some  cases,  but  is  not  a  prominent  symptom.  In  many  instances 
marked    irregular    fever    has  been  observed,  which,  in  a  case  under  my 


172 


MENORRHAGIA    AND    METRORRHAGIA.       EXTRA-UTERINE    PREGNANCY. 


notice,   was  unassociated  with  leucocytosis.      The   uterus  is   usually  enlarged 
to  the  size  of  about  a  three  months'  pregnancy. 

Retro-displacements. — Backward  displacements  of  the  uterus  are  frequently 
accompanied  by  menorrhagia.  The  symptoms,  in  addition  to  the  hemor- 
rhao-e,  are,  pain  in  the  back,  aggravated  by  exertion  and  standing;  a 
feeling  of  weight  and  bearing  down  in  the  pelvis;  and  leucor- 
rhea.  Examination  will  at  once  reveal  the  presence  of  the  displacement,  its 
nature,  and  its  degree. 


Fig.  63. — Subinvolution  of  the  Uterus,  which  is  13  cm.  Long  and  Enlarged  in  the  Proportion 
SHOWN  BY  Comparison  with  the  Normal  Uterus  Superimposed  Above.  This  patient  had 
for  a  long  time  suffered  with  profuse  hemorrhages  at  the  time  of  the  menopaxise.  There  was  no 
tumor  or  malignant  disease. 

Subinvolution  of  the  Uterus. — This  condition  arises  from  the  arrest  of  invo- 
lution in  the  uterus  whicli  has  exj^elled  the  products  of  conception.  It  may 
occur  after  either  a  miscarriage  or  a  labor  at  term.  After  the  increase 
in  size  of  the  uterus  during  the  development  of  the  ovum,  the  organ  normally 


LOCAL    CAUSES    OF    tlTEKlNE    liEMORRIlAGE.  173 

undergoes  retrogressive  changes  by  which  it  is  restored  to  nearly  the  size  which 
it  was  before  impregnation.  But  if  these  retrogressive  changes  fail  to  take 
jDlace,  the  uterus  remains  large  and  boggy,  while  the  endometrium  becomes  thick 
and  succulent  (see  Fig.  63).  The  symptoms  of  this  condition  are  pain  and 
feeling  of  w^ eight  in  the  pelvis,  with  a  sense  of  bearing  down. 
Menorrhagia  is  always  present  and  frequently  leucorrhea.  Examina- 
tion shows  the  uterus  to  be  enlarged,  boggy,  and  frequently 
displaced,  and  these  facts,  together  with  the  history,  which  shows  that  the 
patient  dates  her  condition  from  a  confinement  or  a  miscarriage,  establish 
the  diagnosis. 

Inversion  of  the  Uterus. — Inversion  of  the  uterus  can  occur  under  two  dif- 
ferent conditions:  (1)  Immediately  after  labor,  as  the  result  of 
it  ;  (2)  gradually,  in  a  non-puerperal  uterus  along  with  the 
expulsion  of  a  tumor  attached  to  the  uterine  wall.  The  amount 
of  inversion  varies  from  a  simple  depression  at  the  fundus  (inversio  incom- 
yleta)  to  a  complete  turning  inside  out  of  the  organ  (inversio  completa).  Any 
condition  which  favors  relaxation  of  the  musculature  of  the  uterus  and  a  patu- 
lous cervix,  predisposes  to  inversion.  The  exciting  cause  is  usually  some  direct 
mechanical  pressure  exerted  from  above.  There  seems  good  reason  for  believ- 
ing that  many  cases  of  post-partum  inversion  are  due  to  violence  exercised 
during  labor.  In  the  non-puerperal,  or  pathological  variety,  the  most  common 
cause  is  a  submucous  fibroid  attached  to  the  fundus ;  the  uterine  cavity  below 
the  tumor  is  relaxed  and  the  expulsive  efTorts,  like  those  of  labor,  which  accom- 
pany fibromata,  force  the  tumor  downward,  until  finally,  in  extreme  cases, 
it  passes  through  the  cervix  into  the  vagina,  dragging  with  it  the  portion  of 
the  uterine  wall  attached  to  it.  If  the  tumor  is  submucous  and  becomes 
pedunculate,  the  peritoneal  surface  of  the  uterine  wall  may  undergo  no  dis- 
placement, in  which  case  there  will  be  no  inversion.  If,  on  the  other  hand, 
the  tumor  remains  sessile,  the  whole  thickness  of  the  uterine  walls  and  peri- 
toneum may  follow  as  it  descends,  creating  an  indentation  on  the  peritoneal 
surface  which  is  at  first  slight,  but  gradually  becomes  more  deeply  depressed 
until,  with  the  escape  of  the  uterus  into  the  vagina  and  out  at  the  vulva,  com- 
plete inversion  is  brought  about.  The  tumor  causing  the  inversion  need  not 
arise  from  the  fundus ;  it  may  be  attached  to  a  lateral  wall. 

The  acute  form  of  inversion,  which  immediately  follows  labor,  does 
not  come  within  the  scope  of  this  work.  In  the  chronic  variety  the  com- 
monest symptom  is  menorrhagia,  or  metrorrhagia,  or  both,  since 
hemorrhage  occurs  with  great  ease  from  the  exposed  mucosa.  If  the  inversion 
is  the  result  of  labor,  the  patient  will  give  a  history  of  hemorrhage  dating 
from  it  and  sometimes  state  that  it  was  particularly  severe  just  after  delivery. 
In  the  non-puerperal  variety  there  is  no  such  clue,  and  the  inversion  may 
not  suggest  itself  to  the  physician  as  the  cause  of  the  hemorrhage  for  which 
he  is  consulted,  until  he  makes  a  bimanual  examination.  In  extreme  cases 
a   red,   bleeding,    pyriform   tumor,    about  three  centimetres  in  diameter 


174  MENORRHAGIA    AND    METRORRHAGIA.       EXTRA-UTERINE    PREGNANCY. 

below  and  contracted  above,  will  be  found  filling  the  vagina.  Bimanual  pal- 
pation shows  a  depression  entering  the  tumor  on  its  peritoneal  surface,  while 
the  fundus  is  absent  from  its  normal  position.  When  the  inversion  is  com- 
plete, the  cervix  cannot  be  distinguished  at  the  vaginal  vault,  which  seems 
continuous  with  the  tumor.  If  the  inversion  is  incomplete,  the  cervix 
remains  as  an  enlarged  ring,  into  which  the  sound  may  be  pushed  for  a  short 
distance.  The  presence  of  the  orifices  of  the  uterine  tubes  at  the  lower  end 
of  the  tumor  is  also  a  diagnostic  point  of  considerable  importance.  The 
differential  diagnosis  between  inversion  and  myoma  has  been  given  above  (see 

p.    154:). 

Acute  Endometritis. — This  is  a  rare  condition,  although  often  mentioned. 
There  are  no  special  symptoms  connected  with  it,  and  the  diagnosis  can 
be  made  only  from  examination  of  the  curettings.  Histologic- 
ally, tlie  surface  epithelial  cells  are  often  swollen  to  two  or  three  times  their 
natural  size,  Avhile  the  adjacent  cells  may  be  compressed.  There  is  a  tendency 
to  cell  proliferation  and  between  the  epithelial  cells  are  many  polymorpho- 
nuclear leucocytes  and  small  round  cells.  The  glands  in  the  superficial  por- 
tions show  swollen  epithelium,  with  a  tendency  towards  proliferation,  together 
with  a  small  round-celled  and  polymorpho-nuclear-celled  infiltration.  Some 
of  the  gland  lumina  are  partially  filled  with  leucocytes.  The  deeper  portions 
of  the  glands  are  often  normal.  The  stroma  shows  much  infiltration  super- 
ficially, with  polymorpho-nuclear  leucocytes  and  small  round  cells,  the  infil- 
tration diminishing  towards  the  muscle.  The  muscle  tissue  underneath  is 
rarely  much  altered. 

Chronic  Endometritis. — This  condition  is  also  rare.  The  prevailing  habit  of 
describing  all  uterine  scrapings  as  examples  of  endometritis  is  greatly  to  be 
deplored,  since  it  interferes  with  our  getting  a  satisfactory  knowledge  as  to  the 
real  frequency  of  the  affection  and  tends  to  encourage  unnecessary  operating. 
The  so-called  fungoid  endometritis  is  not  really  a  pathological  entity 
at  all  and  the  name  ought  to  be  avoided.  Chronic  endometritis  is 
oftenest  associated  with  old  cases  of  pyosalpinx  and  is  rarely  found  in  ordi- 
nary scrapings.  The  slight  liability  of  the  uterine  mucosa  to  this  affection 
is  due  to  two  factors:  First,  the  tendency  of  pus-containing  tubes  to  close 
completely  at  the  uterine  end,  by  which  one  avenue  of  infection  is  shut  off; 
second,  the  form  and  position  of  the  uterine  canal,  which  are  such  as  to  afford 
good  drainage.  Chronic  endometritis,  when  present,  is  characterized  by 
the  unevenness  of  the  mucosa,  in  which  the  epithelium  is  stunted,  low,  cylin- 
drical, or  cuboidal.  The  glands,  in  some  places,  are  diminished  in  number 
and  vary  in  size ;  some  of  them  being  narrow  above  and  distended  below.  The 
epithelium  of  the  dilated  glands  is  somewhat  flattened.  The  stroma  is  denser 
than  it  is  normally,  especially  in  the  superficial  portions,  the  nuclei  tend  to 
become  spindle-shaped,  and  there  is  much  round-celled  infiltration.  There  are 
practically  no  poljonorpho-nuclear  leucocytes.  The  deeper  portions  of  the 
stroma  are  often  normal  and  there  are  no  changes  in  the  muscles. 


LOCAL    CAUSES    OF    UTERINE    ItEMORTlXIAGE. 


175 


Hypertrophy  of  the  Endometrium. — Hypertrophy  of  the  endometrium,  some- 
times called  chronic  hyperplastic  endometritis,  is  generally  the  result 
of  an  over-supply  of  blood  to  the  uterus.  Any  condition,  therefore,  which 
induces  pelvic  congestion  is  likely  to  be  accompanied  by  an  increased  growth 
of  the  endometrium.  The  symptoms  are,  profuse  and  prolonged  men- 
stru,ation  with  a  shortening  of  the  intermenstrual  period.  Some- 
times there  is  metrorrhagia,  and  cases  occasionally  occur  in  which  there 
is  a  continual  hemorrhage,  the  menstrual  periods  being  distinguished  by  an 
increase  of  the  flow.  Leu  cor  r  he  a  is  almost  always  present,  occasionally 
tinged  with  blood. 

Examination  shows  a  uterus  increased  in  size  and  weight,  fre- 
quently softer  than  normal  in  the  early  stages  of  the  affection  and  hard  in  the 
later.  There  are  two  different  forms  of  hypertrophy  of  the  endometrium: 
glandular  and  interstitial,  both  of  which  may  exist  at  the  same  time. 
In  the  glandular  form  the  glands,  which  are  increased  in  number,  are 
spiral,  and  the  gland  spaces  are  dilated,  with  an  excess  of  epithelium  in  their 
lumena.  The  surface  epithelium  of  the  endometrium  is  also  proliferated,  but  the 
single  epithelial  layer  in  the  glands  or  on  the  surface  is  never  duplicated,  except 
in  the  senile  form  of  the  affection.  In  interstitial  hypertrophy  there 
is  at  first  a  round-celled  infiltration  of  the  inter-glandular  connective  tissue. 
The  glands  themselves  are  widely  separated  and  compressed.  The  surface 
epithelium  is  sometimes  exfoliated  and  when  the  condition  has  become  chronic 
the  round  cells  become  spindle-shaped.  If  the  glands  are  much  compressed  they 
may  atrophy  and  disappear.  The  uterine  mucosa  becomes  a  single  layer  of 
epithelial  cells  on  the  surface  of  the  uterine  cavity. 

Polypoid  Endometritis. — In  this  form  of  endometritis,  the  uterine  cavity  is 
choked  by  a  mass  of  growths  resembling  multiple  polypi,  in  which  the  glands 


Fig.  64. — Polypoid  Endometritis,  showing  an  Extensive  Papillary  Overgrowth  of  the  Uterine 

Mucosa.      (From  T.   S.   Cullen.) 


are  dilated  and  the  blood  vessels  increased  in  size  and  number  (see  Fig.  64). 
It  is  usually  seen  in  quite  young  women,  and  is  characterized  by  profuse  men- 
strual hemorrhage,  sometimes  of  the  most  severe  description.  The  only  condi- 
tion for  which  it  is  likely  to  be  mistaken  is  malignant  disease,  and  the  di- 


176  :MEXORRriAGiA    and    METRORKHAGIA.       EXTRA-rTERIXE    PREOXAXCT. 

agnosis   is   easily   made   from    the    uterine   scrapings,    ^vhicli   must   always   be 
carefully  examined  under  the  microscope  (see  Chap.  XXI,  p.  527). 

Tuberculosis  of  the  Endometrium. — ^lenorrhagia  is  occasionally  caused  by 
tuberculosis  of  the  endometrium,  which  is  nearly  always  secondary  to 
tuberculosis  of  the  tubes.  It  luay  be  miliary,  a  part  of  a  general  tubercular 
process,  or  of  the  chronic  diffuse  form.  The  chronic  diffuse  form  is  that  with 
which  we  usually  have  to  do.  It  begins,  as  a  rule,  at  the  fundus,  being  sec- 
ondary to  a  tubercular  tube.  The  first  visible  alterations  are  little  yellowish- 
white  nodules  under  the  surface  one  to  two  millimeters  in  diameter,  which  may 
increase  in  size  and  numbers  and  then  coalesce  and  break  down,  forming  an 
ulcer  with  an  undermined  edge.  The  disease  extends  from  the  endometrium 
into  the  uterine  muscle. 

Histological  examination  in  the  early  stages  shows  the  epithelium  of 
the  surface  intact  and  the  glands  normal,  while  the  tubercles  are  found  scat- 
tered throughout  the  superficial  portions  of  the  uterus ;  these  consist  of  agg-rega- 
tions  of  epithelial  cells,  later  they  are  surrounded  by  small  round  cells,  and  at  a 
still  later  stage,  the  giant  cells  are  found  in  the  centre.  The  surface  epithelium 
over  the  superficial  nodule  is  frequently  flattened  and  plain.  In  a  marked 
case  the  glands  are  encroached  upon  and  it  is  at  times  impossible  to  distin- 
guish some  of  the  epithelial  cells  from  the  gland  epithelium ;  in  other  cases 
tubercles  are  seen  partly  projecting  into  and  obliterating  the  gland  cavity; 
and  again,  the  gland  may  be  filled  with  caseous  material.  In  the  most  ad- 
vanced cases  the  cavity  is  lined  by  caseous  material  devoid  of  nuclei,  below 
which  lies  a  zone  of  typical  tubercular  tissue  consisting  of  epithelioid  cells 
and  tubercles ;  in  the  deeper  portions  a  stray  gland  may  survive  where  the 
process  has  gone  deep  enough  to  involve  the  muscle.  The  glands  are  often 
entirely  absent.  Bacilli  are  found  with  varying  frequency,  sometimes  sparse 
sometimes  abundant,  and  most  numerous  in  the  advanced  cases  with  marked 
caseation.  In  my  experience,  they  are  much  more  readily  found  than  in 
tuberculosis  of  the  tubes.  In  the  early  stages  of  the  disease  the  tubercular 
process  may  be  entirely  unsuspected  and  the  curettings  may  look  like  the  nor- 
mal uterine  mucosa:  but  where  the  disease  is  advanced,  the  presence  of  soft 
cheesy  masses  will  at  once  arouse  suspicion.  Xecrotic  carcinomatous  tissue 
may  present  a  somewhat  similar  appearance,  but  the  characteristic  branching 
found  in  cancer  does  not  occur  in  tuberculosis.  In  advanced  cases  the  diag- 
nosis may  be  reached  from  the  examination  of  the  uterine  discharge,  which 
contains  tubercle  bacilli.  It  has  happened  several  times  in  my  experience  that 
tuberculosis  has  been  found  in  a  purely  accidental  way  while  submitting  the 
uterine  scrapings  to  the  routine  examination.  On  other  occasions  I  have  found 
a  tubercular  endometrium  on  curetting  the  uterus  immediately  after  removing 
the  tubercular  tubes. 

Enlarged  Cystic  Ovaries. — Menorrhagia  arising  from  enlarged  cystic  ovaries 
occurs  in  youth,  or  at  any  rate  in  women  under  thirty-five.  There  may  be 
no   symptom   but   hemorrhage. 


LOCAL  CAUSES  OF  UTERINE  HEMOEEHAGE. 


177 


Pelvic  Hematocele. — Menorrhagia  from  this  cause  is  usually  associated 
with  pelvic  inflammatory  disease.  The  symptoms  are  more  or  less  con- 
stant pelvic  pain,  dysmenorrhea,  and  hemorrhage.  Examination 
shows  the  uterus  to  be  full  of  old  viscid  blood ;  it  is  more  or  less  immobile  and 
may  be  tender  on  firm  pressure.  Irregular  lateral  masses  will  be  found  fill- 
ing out  the  pelvis  behind  the  broad  ligaments. 

Corpus  Luteum  Cysts.- — Menorrhagia  is  the  only  symptom  arising  from  this 
form  of  cyst.  It  is  impossible  to  distinguish  it  from  monorrhagia  arising  from 
follicular  cysts.     , 

Inflammation  of  the  Tubes  and  Ovaries. — Menorrhagia  is  a  common  accom- 
paniment of  tubal  inflammation.  The  period  is  lengthened,  the  interval  short- 
ened, and  the  quantity  of  blood  lost  unnaturally  great.  In  rare  instances  the 
monorrhagia  becomes  a  metrorrhagia  so  profuse  and  long  continued  as  to  cause 
profound  anemia  and  actually  threaten  life.  In  exceptional  cases  menstrua- 
tion is  scanty  or  there  may  be  amenorrhea,  by  reason  of  atrophic  changes  in  the 
uterus  and  appendages.  There  is  usually  a  history  of  neurasthenia  and  diges- 
tive disturbances  with  loss  of  weight  and  failing  strength.  Often  there  is  the 
history  of  infection.  Examination  shows  lateral  inflammatory  masses  or  else 
the  uterine  tubes  are  large,  hard,  and  distended  to  a  sausage  shape. 

Extra-uterine  Pregnancy. — Menorrhagia  is  one  of  the  striking  symptoms 
of  an  extra-uterine  pregnancy;  but  usually  something  in  the  history  suggests 
the  cause  of  the  hemorrhage.  In  many  cases  there  will  have  been  the  usual 
symptoms  which  accompany  the  early  stages  of  normal  pregnancy,  namely, 
cessation  of  menstruation,  morning  sickness,  fullness  of  the 
breasts.  The  diagnosis  of  this  condition  is  of  such  importance  that  it  is  con- 
sidered in  a  separate  section  (see  p.  194). 

Sclerosis  or  Atheroma  of  the  Uterine  Blood  Vessels. — The  physician  some- 
times encounters  cases  in  which  monorrhagia,  or  metrorrhagia,  or  both  occur 
in  women  nearing  middle  life,  for  which  none  of  the  causes  just  discussed  can 
be  assigned.  Even  if  the  hemorrhage  is  so  severe  as  to  necessitate  removal 
of  the  uterus  to  save  life,  nothing  will  be  found,  except  that  it  is  somewhat 
enlarged  and  from  a  macroscopic  point  of  view  simply  superinvoluted.  Exami- 
nation with  the  microscope,  however,  shows  sclerotic  changes  in  the  uterine 
blood  vessels.  The  smaller  vessels  in  the  mucosa  are  increased  in  number  and 
their  walls,  instead  of  consisting  of  practically  nothing  but  a  layer  of  endo- 
thelium, are  thickened  by  a  deposit,  around  which  is  a  layer  of  concentric 
lamellffi  of  fibrous  tissue  with  well-stained  nucleii.  This  condition  is  a  local 
affection  which  does  not  involve  the  uterine  artery  and  is  not  associated  with 
a  sclerosis  of  the  other  vessels  of  the  body.  The  diagnosis  of  it  can  be  made 
only  by  exclusion.  It  was  first  noted,  according  to  Barbour,  by  Pichevin  and 
Petit  in  1895  {Gaz.  med.  de  Paris,  ISTov.,  1895)  and  has  since  been  discussed 
by  Barbour  himself  (Jour.  Ohst.  and  Gyn.  of  Brit.  Emp.,  1905,  vol.  7,  p.  387) 
and  by  E.  L.  Dickinson  [BrooMyn  Med.  Jour.,  1906,  vol.  20,  p.  45).  Let  me 
utter  a  word  of  caution  here,  however,  against  considering  every  woman  who 
13 


178  INIElSrORRHAGIA    AND    METROEETTAGIA.       EXTEA-UTEEINE    PEEGNANCT. 

suffers  from  liemorrhage  at  the  meuopause,  aud  has  been  shown  free  from 
cancer,  to  be  a  case  of  capillary  sclerosis.  There  are  many  cases  of  "  symp- 
tomatic hemorrhage  "  at  the  time  of  the  climacteric  which  recover  with  rest, 
packing-,  and  the  exercise  of  a  little  patience. 

Calcification  of  the  Uterine  Blood  Vessels. — Henri  Arnal,  in  a  thesis  on  the 
senile  nterns  (Abst.  by  P.  Petit,  La  sem.  gyn.,  190G,  vol.  11,  p.  33)  has 
pointed  ont  that  calcification  of  the  nterine  blood  vessels  is  by  no  means  infre- 
quent, being-  present  in  fifty  per  cent  of  the  uteri  observed  by  him.  The  degen- 
eration begins  in  the  middle  fibrous  coat  of  the  artery  and  extends  towards 
the  periphery  or  the  inner  coat,  sometimes  invading  and  breaking  down  the 
latter.  The  degree  of  calcification  is  not  in  proportion  to  the  age  of  the  patient ; 
for  example,  there  were  no  more  calcified  vessels  in  a  woman  of  eighty-seven 
than  in  another  woman  of  sixty.  Tt  seems  probable,  therefore,  that  other  fac- 
tors than  mere  age  enter  into  the  degenerative  process,  possibly  the  same  which 
are  observed  in  angio-sclerosis  of  the  uterus  before  the  menopause, 
or  in  neuro-arthritis.  These  vascular  lesions  are  liable,  of  course,  to 
cause  the  formation  of  intraparietal  hematometra,  accompanied  by 
more  or  less  hemorrhage,  and  this  form  of  metrorrhagia,  which  has  been  little 
noted,  is  important,  because  any  hemorrhage  from  the  uterus  after  the  meno- 
pause is  liable  to  be  taken  as  evidence  of  cancer.  In  any  suspicious  case  the 
uterus  should  be  curetted  and  the  scrapings  carefully  examined.  This  condi- 
tion is  frequently  associated  with  grave  vascular  lesions  in  other  parts  of  the 
body;  one  patient  of  Petit's  died  from  the  effects  of  a  pulmonary  embolism 
and  another  from  a  thrombus  in  the  left  cerebral  hemisphere. 

I  have  investigated  the  frequency  with  which  the  different  local  causes 
just  discussed  are  found  in  menorrhagia,  with  the  following  results :  Out  of 
three  thousand  nine  hundred  and  fifty-four  gynecological  cases  treated  in  the 
Johns  Hopkins  Hospital  between  June  11,  1894,  and  March  25,  1899,  there, 
were  six  hundred  and  seven  in  which  hemorrhage  from  the  uterus  occurred. 
The  local  causes  associated  with  them  are  these : 

Carcinoma  uteri,  one  hundred  and  sixty  cases,  or  tv:enty-six  and  three- 
tenths  per  cent. 

Myomata  (simple  and  uncomplicated),  one  hundred  and  twenty -nine  cases, 
or  twenty-one  and  three-tenths  per  cent. 

Myomata  (complicated  with  pelvic  inflammatory  disease),  twenty-two  cases, 
or  three  and  six-tenths  per  cent. 

Pelvic  infiammatory  disease  (alone),  eighty-three  cases,  or  thirteen  and 
seven-tenths  per  cent. 

Abortion  and  sequelae,  forty  cases,  or  six  and  five-tenths  per  cent. 

"  Endometritis,"  thirty-two  cases,  or  five  and  three-tenths  per  cent. 

Petroflexion  of  the  uterus,  twenty-nine  cases,  or  four  and  eight-tenths  per 
cent. 

Relaxed  vaginal  outlet,  twenty-three  cases,  or  three  and  a  half  per  cent. 

Polypi  of  uterus,  twenty  cases,  or  three  and  two-tenths  per  cent. 


CONSTITUTIOlSrAL    AND    VASCULAR    CAUSES    OF    UTERINE    HEMORRHAGE.         179 

Extra-uterine  pregnancy,  seventeen  cases,  or  two  and  eight-tenths  per  cent. 

Cystoma  of  the  ovaries,  twelve  cases,  or  one  and  nine-tenths  per  cent. 

Other  causes  were :  Anteflexion  of  the  uterus ;  sarcoma  of  the  uterus ;  each 
three  cases.  Stenosis  of  the  cervix  uteri;  sarcoma  of  the  ovary;  pregiiancy; 
each  two  cases.  Pyometra;  hematometra;  corpus  luteum  cyst;  retroposition ; 
hemophilia ;  cyst  of  Gartner's  duct ;  fibroma  of  the  ovary  (malignant)  ;  dilated 
glands  ;  subinvolution ;  gland  hypertrophy ;  "  menorrhagia  and  metrorrhagia ;  " 
each  one  case. 

Of  the  six  hundred  and  seven  cases,  eighty-seven  showed  menstruation  to 
be  prolonged  or  profuse,  or  both ;  and  of  these  eighty-seven,  fifty-seven,  or 
sixty-five  per  cent,  were  cases  of  myoma  of  the  uterus,  including  myomata 
complicated  with  pelvic  disease. 

CONSTITUTIONAL   AND  VASCULAR  CAUSES. 

The  diagnosis  of  uterine  hemorrhage  arising  from  constitutional  or  vascular 
causes  must  rest  upon  the  history  of  the  case  and  the  exclusion  of  any  local 
cause.  In  young  girls  the  establishment  of  the  menstrual  function  is  often 
attended  with  irregularities  which  may  manifest  themselves  in  excess  as  well 
as  in  deficiency.  The  following  case  is  an  illustration  of  how  much  may  be 
done  in  such  menorrhagias  by  patience  and  the  employment  of  palliative 
measures. 

Miss  G-.,  age  sixteen,  J.  H.  H.,  'No.  11750,  Dec,  1904.  The  patient  was 
always  in  good  health  until  she  was  fourteen,  when  she  began  to  menstruate. 
Menstruation  was  too  frequent  and  too  profuse  from  the  onset,  the  periods 
recurring  every  two  weeks.  At  first  the  flow  lasted  only  two  days,  but  by  the 
end  of  two  years,  at  which  time  she  entered  the  hospital,  the  hemorrhage  had 
become  almost  continuous.  Her  hemoglobin  count  was  then  only  forty-eight  per 
cent.  She  had  been  curetted  three  times  and  the  last  time  a  surgeon  of  high 
standing  had  said  that  the  hemorrhage  was  caused  by  cancer  and  that  a 
hysterectomy  was  the  only  means  of  saving  her  life.  I  curetted  her  as  soon  as 
she  came  under  my  care,  and  removed  an  excessive  amount  of  pale,  flabby, 
endometrium,  in  long  projecting  tufts.  She  was  discharged  at  the  end  of 
three  weeks,  but  the  hemorrhage  shortly  returned  and  she  was  re-admitted 
about  four  months  later.  Her  hemoglobin  count  was  then  only  forty  per  cent. 
I  curetted  the  uterus  again  and  cauterized  it,  with  relief  from  hemorrhage  for 
nearly  a  year,  when  the  flow  again  became  excessive.  I  then  curetted  a  third 
time,  making  in  all  six  curettings  in  three  years.  This  last  curettage  was  in 
May,  1906,  and  in  June,  1907,  a  little  over  a  year,  she  was  free  from  more 
than  a  slight  excess  in  menstruatir*n. 

There  is  a  rare  form  of  chlorosis  in  which  the  uterus  and  ovaries, 
instead  of  being  small  or  even  infantile,  as  is  usually  the  case  in  this  affection, 
are  markedly  increased  in  size,  while  menstruation,  instead  of  being  deficient 
in  amount,  is  excessive. 

An  occasional  constitutional  cause  of  menorrhagia,  not  often  recognized^  is 


180  MENOERHAGIA    AND    METROERHAGIA.       EXTRA-UTERINE    PREGNANCY. 

syphilis.  B.  MacMonagle;  of  San  Francisco,  lias  had  a  case  of  persistent 
menorrhagia  which  nothing  relieved  until  a  complaint  made  b}'  the  patient  of 
dizziness  and  a  tendency  to  fall  clown,  suggested  specific  disease  and  led  Dr. 
MacMonagle  to  prescribe  iodide  of  potash;  this  relieved  the  head  symptoms, 
and  immediately  afterward  the  menorrhagia  disappeared. 

In  making  a  diagnosis  as  to  the  cause  of  any  case  of  menorrhagia,  the 
physician  will  do  well  to  bear  in  mind  the  age  and  condition  of  the  patient. 
If  she  is  a  yoimg  girl,  malignant  disease  of  any  kind  may  generally  be  ex- 
cluded, and  in  all  probability  several  other  local  causes.  In  the  case  of  yoimg 
girls  the  irregularity  is  most  apt  to  be  caused  by  the  slow  and  imperfect 
development  of  the  uterine  vessels,  in  the  last  stage  of  her  corporeal 
evolution.  Chlorosis  is  sometimes  associated  with  this  state  of  things. 
Young  girls  are  also  apt  to  suffer  from  an  excessive  flow  following  influenza, 
pneumonia,  scarlet  fever,  or  small-pox.  A  persistent  hemorrhage  in  their  case 
is  sometimes  associated  with  a  glandular  polyp,  or,  more  rarely,  with  a 
polypoid  endometritis.  Family  tendencies  must  also  be  borne  in 
mind.  In  umnarried  women  between  thirty  and  forty  years  of  age,  excess  of 
menstruation  is  most  likely  caused  by  a  slight  displacement  (retroflexion 
as  a  rule),  in  eases  where  the  increase  begins  suddenly.  "When  the  onset 
is  gradual,  it  is  probably  caused  by  a  polyp,  or  else  by  a  fibroid  tumor, 
or,  quite  frequently,  by  tuberculosis   of   the   uterine   tubes. 

In  married  women,  a  threatened  or  an  incomplete  abortion  must 
always  be  assumed  as  the  efficient  cause  until  its  existence  is  disproved. 
Fibroid  tumors  also  frequently  come  into  play  with  this  class  of  cases. 
Almost  every  woman  who  presents  herself  in  the  late  thirties  with  large  fibroids 
and  a  history  of  menorrhagia  will  also  give  a  history  of  an  excessive  fiow  for 
some  years  previous,  the  cause  of  which  had  not  been  recognized. 

After  the  age  of  thirty-five,  cancer  comes  into  play  as  an  active  cause 
of  hemorrhage.  The  frequency  with  which  this  disease  exists  makes  it  impera- 
tive to  be  always  on  the  watch  for  it,  in  order  that  it  may  be  recognized  at  the 
earliest  possible  moment.  Every  week  of  delay  in  active  treatment  (extirpa- 
tion) of  cancer  is  precious  time  lost.  If  a  woman  over  forty  is  troubled  with 
an  increasing  instead  of  a  diminishing  menstrual  flow,  sometimes 
marked  in  its  earliest  stages  by  a  watery  discharge,  and  if,  on  examina- 
tion, the  uterus  is  found  somewhat  enlarged,  cancer  of  the  uterine 
body   is  to  be  suspected 

The  investigation  of  any  case  of  uterine  hemorrhage  should  be  carried  on 
as  follows:  First,  a  careful  history  must  be  taken  in  which  the  patient's  age 
and  condition  are  noted,  together  with  her  family  history  and  its  tendencies. 
Second,  a  careful  physical  examination  of  the  chest  and  abdomen  must  be 
made,  when,  if  anything  amiss  is  discovered,  as  for  example,,  a  bad  heart  lesion, 
the  diagnosis  may  be  cleared  up  at  once.  I  have  seen  a  case  in  which  the 
patient  came  into  the  dispensary  complaining  of  menorrhagia  and  with  a  his- 
tory which  suggested  no  local  cause  except,  possibly,  incomplete  abortion.     It 


GENBKAL    DIRECTIONS    FOK    DIAGNOSIS    OF    UTERINE    HEMORRHAGE.  181 

was  observed,  however,  that  she  was  extremely  short  of  breath,  and  examina- 
tion of  her  heart  showed  that  it  was  enormously  dilated.  Examination  of 
the  pelvic  organs  showed  no  local  trouble  of  any  kind.  Systematic  treatment 
for  the  heart  lesion  improved  her  general  condition  greatly  and  with  this 
improvement  the  monorrhagia  was  also  much  relieved. 

Let  me  here  utter  a  word  of  protest  against  the  too  hasty  local 
examination  of  young  unmarried  women  made  by  many  practition- 
ers and  pseudo-specialists.  In  almost  all  such  cases  it  is  best  to  assume  that 
the  simpler  condition  (e.g.,  constitutional  disturbances)  accounts  for  the  trouble, 
and  to  use  appropriate  remedial  measures  for  general  treatment,  endeavoring 
above  all  to  gain  the  kindly  aid  of  time  in  setting  things  right.  If,  however, 
an  excessive  flow  persists  in  spite  of  all  measures  for  its  relief,  an  examination 
should  be  made  under  an  anesthetic,  when  appropriate  measures  for  relief 
can  be  taken  at  the  same  time. 

In  a  married  woman,  or  in  an  unmarried  one  with  a  long  history  of  ex- 
cessive menstruation,  there  should  be  no  delay  in  making  an  examination.  A 
simple  inspection  of  the  introitus,  revealing  the  deep  bluish  color  of  pregnancy, 
may  clear  up  the  diagnosis  at  once.  The  finger  introduced  may  at  once  touch 
a  polyp  lying  in  the  vagina  or  feel  its  smooth  surface  just  within  the  cervix. 
A  softened  cervix  is  a  sign  of  pregnancy,  while  a  nodulated  enlarged 
cervix,  due  to  endocervicitis,  or  a  friable  cancerous  cervix  speaks 
for  itself  at  once.  A  bimanual  examination  is  next  in  order  to  detect  any 
enlargement  of  the  uterine  body,  should  it  exist,  and  if  it  does,  to 
determine  whether  it  is  uniform  and  more  or  less  globular,  in  which  case  it  is 
due  to  pregnancy,  to  a  subinvoluted  uterus,  a  cancerous  uterus, 
or  a  polyp  within  the  uterine  body.  Fibroid  tumors  are  usually 
asymmetrical  and  multiple.  Diseased  conditions  lateral  to  the  uterus, 
such  as  the  unilateral  tumor  of  extra-uterine  pregnancy,  a  malig- 
nant ovarian  tumor  of  greater  or  less  size,  or  the  hardness  and  tender- 
ness induced  by  an  inflammatory  condition  of  the  ovaries,  if  -they 
are  marked,  may  all  be  at  once  detected. 

If  the  diagTLOsis  is  not  clear,  it  is  best  for  diagnostic  purposes  to  make  a 
more  thorough  examination  of  the  uterus  and  the  lateral  structures  by  putting 
the  patient  completely  under  the  control  of  the  examiner  through  the  use  of  an 
anesthetic.  Whenever  an  anesthetic  is  used  for  diagnostic  purposes,  it  is 
well  to  obtain  the  patient's  consent  beforehand  to  the  performance  of  any  sim- 
ple operation  which  may  be  required,  such,  for  example,  as  a  curettage. 

Let  me  note  here  that  the  cases  which  most  often  escape  diagnosis  are  those 
in  which  there  is  a  small  polyp  or  fibroid  tumor,  perhaps  not  over 
half  an  inch  in  diameter,  in  the  uterine  cavity.  In  several  such  cases  occur- 
ring in  women  under  forty,  where  I  have  excluded  every  other  local  cause, 
I  have  opened  the  body  of  the  uterus  through  the  vagina  by  detaching  it  from 
the  bladder  and  splitting  it  up  the  anterior  wall ;  or  else,  through  the  abdo- 
men, making  an  incision  in  an  antero-posterior  direction  through  the  fundus 


182  MENORKHAGIA    AND    METEOKEHAGIA.       EXTEA-rTEEINE    PEEGNANCT. 

into  tlie  cavity,  as  though  I  were  about  to  cleave  the  organ  into  two  parts.  A 
little  tumor  inaccessible  by  the  ordinary  means  of  exploration  has  thus  been  dis- 
covered and  removed  with  entire  relief  of  the  hemorrhage.  A  case  of  this  kind 
is  the  following: 

The  patient  complained  of  excessive  flow;  and  on  examination  the  uterus 
felt  enlarged  and  thick,  but  nothing  else  could  be  observed.  The  cervix  was 
therefore  pulled  down  to  the  outlet,  dissected  away  from  the  vaginal  vault,  and 
freed  nearly  up  to  the  os  internum.  It  w^as  then  split  up  into  the  uterine 
cavity  and  the  finger  introduced.  A  mucous  polyp  as  large  as  the  end  of  a 
thmnb  was  at  once  felt  on  the  posterior  wall  towards  the  left.  This  was 
curetted  off  Avith  a  large  scoop  curette.  The  cervix  was  then  closed  with  buried 
catgut  sutures  and  the  vagina  tmited,  with  a  narrow  iodoform  gauze  drain  in 
the  centre. 

Several  times,  on  opening  the  uterus  in  this  way,  I  have  found  nothing 
but  a  peculiar  feathery  condition  of  the  endometrium,  particu- 
larly marked  in  the  cornua  of  the  uterus,  and  after  this  had  been  thoroughly 
removed  by  the  curette  the  hemorrhage  ceased. 

In  the  midst  of  all  these  possible  causes,  the  diagnosis  of  the  cause  of 
uterine  hemorrhage  may,  to  a  comparatively  inexperienced  practitioner,  appear 
a  matter  of  the  utmost  difficulty.  This  is  not  the  case,  however,  for,  as  a  rule, 
it  is  quite  easy  to  say  that  the  hemorrhage  springs  from  a  certain  source  within 
a  few  minutes  after  seeing  the  patient.  As  soon  as  the  causes  just  discussed 
receive  a  little  clear  analysis  they  will  be  found  to  fall  into  groups,  and  there- 
fore it  is  not  necessary  to  go  over  every  possibility  with  painstaking  care  in 
order  to  reach  a  diagnosis  by  exclusion.  For  example,  if  a  patient  comes 
into  the  physician's  ofiice  out  of  breath  and  cyanosed,  and  the  fingers  touching 
the  pulse  detect  an  irregularity,  there  is  at  least  a  suggestion  that  the  cause 
of  the  uterine  hemorrhage  which  she  complains  of  lies  in  a  valvular  heart 
lesion.  Again,  a  patient  with  extreme  anemia  comes  in,  and  in  answer  to  the 
question  whether  the  anemia  began  first  and  was  followed  by  the  hemorrhage, 
or  vice  versa,  she  asserts  that  the  hemorrhage  came  first.  This  makes  it  clear 
that  the  hemorrhage  is  probably  due  to  a  local  lesion,  and  if  the  hand  placed 
upon  the  abdomen  recognizes  an  enlarged  nodular  uterus,  the  cause  is  appar- 
ent— the  hemorrhage  comes  from  uterine  fibroids.  Or,  it  may  be,  that  the 
patient  volunteers  the  information  that  she  was  pregnant  one  or  two  months 
when  the  hemorrhage  began,  when  examination  will  likely  reveal  a  threatened 
or  an  incomplete  abortion. 

When  there  is  no  obvious  cause  the  question  must  be  approached  somewhat 
after  this  manner:  There  is  no  manifest  systematic  disease  and  judging  by 
the  fact  that  the  trouble  began  recently,  the  cause  is  probably  a  local  one.  This 
being  the  case,  a  pelvic  examination  must  be  made,  when  it  may  be  that  the 
vagina  will  be  found  normal  and  that  there  will  be  no  evidence  of  lateral  dis- 
ease in  the  tubes  and  ovaries,  but  as  soon  as  the  cervix  is  seen  the  matter  will 
be  settled  hj  the  evidences  of  carcinoma.     From  this  time  on  then,  the  whole 


GEISTEEAL    TREATMENT    OF    UTERINE    HEMORRHAGE.  183 

attention  can  be  concentrated  upon  the  uterus  as  the  organ  from  which  the 
hemorrhage  proceeds  and  as  that  in  which  the  cause  of  it  is  to  be  found. 

If,  however,  the  cervix  proves  normal,  the  next  question  will  be:  is  the 
uterus  enlarged  ?  If  it  is,  the  enlargement,  if  nodular,  may  be  due  to  a  myoma 
or  a  sarcoma ;  or  if  it  is  uniform,  to  a  pregnancy  or  a  carcinoma  of  the  fundus. 
It  must  always  be  borne  in  mind,  however,  that  small  nodules  may  be  found  in 
carcinoma. 

If  all  these  manifest  signs  fail,  the  patient  must  be  more  minutely  exam- 
ined under  anesthesia  and,  if  necessary,  the  uterus  must  be  dilated  and  curetted, 
in  order  that  the  scrapings  of  the  mucosa  may  be  examined  under  the  micro- 
scope, for  such  an  examination  may  reveal  an  incipient  carcinoma,  an  endo- 
metritis, or  the  remains  of  an  abortion. 

TREATMENT. 

The  treatment  of  uterine  hemorrhage  in  order  to  be  efficient  must  reach 
the  cause;  it  is  plain,  therefore,  that  a  correct  diagnosis  is-  essential 
to  a  cure.  Sometimes  it  happens  that  the  diagnosis  and  the  treatment 
proceed  pari  passu,  as,  for  example,  in  curettage  of  the  endometrium,  when 
a  diagnosis  is  made  and  a  cure  effected  at  the  same  time. 

The  hemorrhage  arising  from  irregularity  in  the  establishment  of  men- 
struation in  young  girls  is  best  treated  as  a  physiological  affection  of  the  young 
tissues  which  are  taking  on  a  new  function.  Rest  is  the  prime  factor  in 
such  cases,  that  is  to  say,  rest  in  bed  for  two  to  three  days  in  each  menstrual 
period,  beginning,  if  possible,  before  the  flow  appears.  Dr.  Ethel  Vaughan 
finds  that,  many  young  girls  are  entirely  relieved  by  abstinence  from  active 
exercise,  such  as  long  walks,  the  use  of  the  bicycle,  or  playing  tennis  just 
before  menstruation.  If  due  precautions  of  this  kind  are  observed  for  from 
six  months  to  a  year,  a  proper  norm  will  probably  be  established.  It  is  most 
important  to  keep  the  bowels  well  regulated,  and  a  course  of  tonic  treatment 
is  an  excellent  adjuvant.  I  should,  for  example,  give  arsenic  and  quinine  in 
some  such  formula  as  this : 

^   Acidi    arsenios gi"-  sV 

Quin.   sulph gr.  ^ 

Extr.  calumb gr.  j 

M.  et  ft.  pil.  j.    Mitte  tales  1. 

S.      One  pill  three  times  daily. 

Iron  is  best  avoided  in  this  class  of  cases  and  ergot  is  of  no  value.  Strych- 
nin, however,  is  often  useful.  A  good  way  to  equalize  the  circulation  is  to 
draw  blood  from  the  pelvic  organs  by  giving  the  patient  a  hot  bath  and  putting 
her  to  bed.  If,  in  spite  of  all  precautions  and  general  remedial  measures,  the 
flow  continues  excessive,  an  examination  must  be  made,  and  if  the  case  seems 
suitable  for  curettage  it  may  be  performed  at  the  same  time.      In  treating 


18-1  MEXOEEHAGIA    AXD    METROEEIIAGIA.       EXTEA-UTEEIXE    PEEGXAXCT. 

yoimg  girls  or  yoimg  unmarried  women,  no  benefit  arises  from  persistent  local 
treatment  in  the  form  of  donches  and  applications ;  sncli  measures  as  these 
should  in  every  case  be  assiduously  avoided.  Attention  of  this  kind  is  well 
described  as  "  gynecological  tinkering." 

In  cases  of  severe  hemorrhage  it  becomes  necessary  to  treat  the  hemorrhage 
independently  of  the  local '  cause,  which  must  be  dealt  with  later  on.  The 
measures  likely  to  be  useful  in  immediate  treatment  are  as  follows:  Rest  in 
bed  in  the  reciunbent  position  with  the  foot  of  the  bed  elevated  about  ten 
inches.  Absolute  quiet  must  be  enforced  in  the  patient's  room,  no  visitors 
should  be  admitted,  and  all  occasion  for  excitement  or  worry  excluded.  The 
bowels  must  be  carefully  regulated,  preferably  with  salines.  Some  of  the 
medicinal  remedies  discussed  below  should  be  given,  and,  if  the  flow  still 
persists,  the  vagina  must  be  tamponed  according  to  the  directions  given. 

In  extreme  cases  it  may  be  necessary  to  give  an  injection  of  normal  saline 
solution.  The  best  method  of  doing  this  is  to  infuse  the  solution  into  the 
cellular  tissue  under  the  breasts,  as  follows :  two  bottles  are  prepared,  each  con- 
taining a  litre  fthirty-four  fluid  ounces)  of  a  sixth-tenths  per  cent  salt  solu- 
tion, at  a  temperature  of  100°  Y.  This  can  be  prepared  by  adding  a  small 
teaspoonful  of  common  salt  to  a  pint  of  water.  A  rubber  tube,  six  feet  long, 
is  placed  in  each  bottle,  attached  to  which  is  a  long,  slender,  sharp  aspirating 
needle.  Instead  of  two  bottles  and  tubes,  one  bottle  can  be  used  with  a  T 
attachment.  The  solution  must  be  free  from  all  organic  particles,  such  as 
bits  of  cotton  from  the  plug  in  the  bottle  in  which  it  has  been  sterilized.  The 
skin  of  the  breast  is  carefully  disinfected,  after  which  the  breast  is  grasped 
and  lifted  up  from  the  chest,  while  the  needle,  with  the  salt  solution  flowing 
into  it,  is  thrust  into  the  cellular  tissue,  well  under  the  glandular  substance. 
The  bottle  is  elevated  above  the  patient  about  six  feet,  in  order  to  give  a 
sufiicient  hydrostatic  pressure  to  force  the  fluid  into  the  tissues.  As  a  rule, 
it  requires  about  twenty  minutes  to  infuse  from  seven  hundred  to  a  thousand 
cubic  centimetres  of  the  solution  under  both  breasts,  taking  one  after  the  other. 
If  the  svmptoms  are  urgent,  both  breasts  may  be  infused  at  the  same  time. 
As  the  infusion  proceeds  the  gland  becomes  greatly  distended,  and  not  infre- 
quently the  salt  solution  spurts  out  of  the  nipple  in  a  fine  jet.  At  the  com- 
pletion of  the  operation,  a  piece  of  adhesive  plaster  must  be  placed  over  the 
point  of  puncture,  to  prevent  a  reflux  of  some  of  the  injected  fluid.  In  none  of 
the  cases  in  which  I  have  employed  this  form  of  repletion  of  the  circulation  has 
there  been  the  slightest  ill  effect  in  the  way  of  local  inflammation  about  the 
breasts. 

The  various  measures  for  the  relief  of  uterine  hemorrhage  may  be  divided 
into  four  classes ;  namely,  medicinal,  mechanical,  surgical,  and  con- 
stitutional. 

Medicinal  Measures. — There  are  various  drugs  which  have  considerable  in- 
fluence in  controlling  uterine  hemorrhage,  though  there  are  none  which  can 
be  depended  upon  to  effect  a  permanent  cure. 


MEDICIKAL    TREATMENT    OF    UTEKINE    HEMOKKHAGE.  185 

Ergot. — Ergot  is  a  remedy  much  in  use  formerly,  but  largely  abandoned 
now.  It  is  given  in  the  form  of  the  fluid  extract,  dose  fifteen  drops  in  water, 
or  as  ergotin,  dose  one-tenth  to  three-fourths  of  a  grain  in  pills. 

Hydrastis  canadensis. — This  drug,  commonly  known  as  Golden  Seal, 
has  a  direct  action  on  the  vaso-motor  nerves  and  is  therefore  useful  in  cases  of 
sub-involution,  interstitial  fibroids,  and  all  forms  of  uterine  con- 
gestion. The  dose  of  the  fluid  extract  is  fifteen  to  thirty  drops  in  water,  three 
or  four  times  a  day ;  or  it  may  be  given  in  the  form  of  hydrastin,  dose  one-eighth 
to  one-fourtli  of  a  gTain  in  pills.  It  is  best  to  give  it  during  the  intermenstrual 
jjeriod  or  else  to  begin  the  administration  a  week  before  the  flow  is  expected. 

Viburnum  prunifolium. — This  is  a  remedy  highly  recommended  for 
use  in  the  monorrhagia  associated  with  constitutional  conditions, 
or  in  that  which  accompanies  the  establishment  or  cessation  of  men- 
struation. The  fluid  extract  is  the  best  form  for  its  use,  dose  thirty  drops 
to  two  teaspoonfuls. 

Apiol. — Apiol  (garden  parsley)  has  recently  been  much  spoken  of  in  the 
treatment  of  monorrhagia.  I  have  seen  a  case  in  which  it  gave  great  relief. 
It  should  be  given  between  the  menstrual  periods  in  the  form  of  capsules,  dose 
three  to  six  minims,  several  times  a  day,  or  else  it  should  be  begun  just  before 
the  period  and  continued  through  the  first  day  or  two. 

Styptic  in. — This  is  a  drug  which  has  found  favor  in  the  treatment  of 
uterine  hemorrhage  Avithin  the  last  few  years.  Abegg  (Centrhl.  f.  Gyn.,  1899, 
vol.  23,  p.  1333)  has  written  of  it  in  the  most  favorable  terms.  Unlike  ergot 
it  does  not  cause  uterine  contractions,  its  hemostatic  action  being  central.  The 
blood  pressure  is  lowered  and  it  has  a  certain  sedative  action  which  relieves  the 
pain  associated  with  menorrhagia.  According  to  Gottschalk,  it  is  useful  in  the 
following  conditions:  (1)  Climacteric  hemorrhage;  (2)  subinvolution  which 
does  not  depend  on  placental  or  membranous  retention;  (3)  fiemorrhage  of 
reflex  order,  caused  by  disease  of  the  appendages  or  of  the  parametrium,  when 
the  uterus  itself  is  healthy;  (4)  congestive  hemorrhage  in  young  girls;  (5) 
hemorrhage  due  to  fibroids  (but  not  to  submucous  polyp).  In  Gottschalk's 
opinion  the  action  of  the  drug  is  more  certain  if  it  is  injected  into  the  gluteus 
muscle.  For  hypodermic  use  a  ten  per  cent  aqueous  solution  is  best,  the  dose 
being  one  to  two  minims. 

Styptol  is  recommended  by  K.  Witthauer  {Centrhl.  f.  Gyn.,  1904,  vol. 
28,  p.  997)  as  being  cheaper  and  more  efficacious  than  stypticin.  The 
dose  is  one  grain,  three  times  daily,  until  the  fiow  begins,  when  one  and  a 
half  grains  are  given  every  three  hours  through  the  period. 

Adrenalin. — The  extract  of  the  adrenal  glands  has  been  given  for  the 
relief  of  menorrhagia  with  some  success.  The  dose  is  fifteen  drops  of  a 
1 :  1000  solution,  three  times  a  day. 

Calcium.  Chloride. — This  is  occasionally  of  service,  in  doses  of  five 
grains  after  each  meal  during  the  intermenstrual  period,  the  frequency  being 
increased  to  intervals  of  two  hours  during  menstruation. 


186  MENORRHAGIA    AND    METRORRHAGIA.       EXTRA-UTEEINE    PREGNANCY. 

Gallic  Acid. — This  is  a  remedy  higbly  recommended  by  T.  A.  Eimnet 
and,  more  recently,  by  W.  L.  Tajdor.  Both  Emmet  and  Taylor  advise  com- 
bining the  acid  with  cinnamon,  which  has  also,  in  their  opinion,  a  bene- 
ficial effect  in  controlling  hemorrhage.  It  may  be  done  after  the  following 
formula : 

^   Acidi  gallici oij 

Tinct.    cinnam fovj 

Aq.  dest.,  q.  s.  ad fovj 

M.     S.   One  tablespoonful  every  three  or  four  hours. 

In  cases  where  there  is  marked  congestion  of  the  uterus  or  ovaries,  Taylor 
finds  great  benefit  from  combining  one  of  the  bromides  with  cinnamon  and 
ergot  in  the  following  formula : 

J^   Ferri  exsiccat gr.  viij 

Potass,   bromid Sjss. 

Ext.  ergot,  fl f3ij 

Tinct.  cinnam f5vj 

M.      S.   One  to  two  teaspoonfuls  three  times  daily. 

Mechanical  Measures. — The  mechanical  measures  used  for  the  relief  of  uter- 
ine hemorrhage  are:  Hot  douches;  tampons  (packs);  cold  applica- 
tions ;    electricity  ;   intra-uterine   applications. 

Hot  Douches. — This  mode  of  treatment  is  highly  recommended  by  many 
authorities.  The  mode  of  administration  is  as  follows :  The  patient  should  lie 
in  the  dorsal  position  with  the  hips  on  a  bedpan,  so  that  the  vaginal  vault 
is  below  the  orifice  of  the  vagina  and  the  water  will  be  in  direct  contact  with 
the  pelvic  organs  while  it  is  in  circulation.  The  temperature  should  be  between 
110°  and  120°  F.  A  lower  temperature  than  this  is  not  only  ineffectual,  but 
injurious,  because,  instead  of  stimulating  the  blood  vessels  to  contract,  it  re- 
laxes them.  Each  douche  should  last  from  fifteen  to  twenty  minutes,  and  one 
to  two  gallons  of  water  is  usually  sufficient.  Tmce  a  day,  morning  and  night, 
is  generally  often  enough  to  use  a  douche,  but  there  are  some  cases  in  which 
it  may  be  necessary  to  give  it  three  times  a  day.  As  a  rule,  the  injections  are 
used  between  the  menstrual  periods  and  discontinued  when  menstruation  ap- 
pears, but  if  the  flow  is  greatly  in  excess,  there  is  no  objection  to  using  them 
throughout  the  period. 

Vaginal  Tampons  (packs). — The  vaginal  tampon  is  a  most  efficient 
means  of  controlling  uterine  hemorrhage.  In  cases  where  the  amount  of  blood 
is  greatly  in  excess  from  the  beginning  of  the  flow,  the  tampons  should  be 
introduced  soon  after  menstruation  begins,  but  if  the  loss  of  blood  is  due  to 
prolongation  of  the  menstrual  period,  it  is  better  to  wait  for  several  days  after 
menstruation  has  been  established  before  inserting  the  pack.  Tampons  are 
made  of  non-absorbent  cotton,  of  wool,  of  lamb's  wool  in  bulk,  or,  sometimes, 


MECIIxVNICAL    TEEATMENT    OF    UTERINE    HEMORRHAGE.  187 

of  strips  of  gauze.  To  insert  the  tampons  a  trivalve  speculum  is  necessary,  if 
the  patient  is  in  the  dorsal  position ;  a  Sims'  speculum,  if  the  Sims'  position 
is  used;  or,  better  still,  a  Kelly's  cylindrical  metal  speculum,  with  the  patient 
in  the  knee-breast  position,  when  the  vagina  balloons  out  and  is  easily  distended 
with  a  firm  pack  to  its  utmost  capacity.  A  tampon  should  remain  in  place 
from  eighteen  to  twenty-four  hours.  When  it  is  removed  the  parts  should  be 
carefully  cleansed  by  a  douche  and  another  pack  inserted. 

Uterine  Tampons. — Intra-uterine  tampons  of  sterilized  gauze  may  be 
used,  packed  very  tight  and  left  in  position  for  forty-eight  hours.  These 
cannot  be  introduced,  however,  without  extensive  dilatation  of  the  cervix,  and 
they  are  not  generally  of  much  service,  except  in  abortions.  Bouriaut  of 
Geneva  has  suggested  that  intra-uterine  injections  of  a  two  per  cent  solution 
of  glycerin  should  be  used  instead  of  tampons.  Ten  to  fifteen  cubic  centimetres 
(about  half  an  ounce)  of  the  solution  are  injected  and  the  injection  is  repeated 
two  to  four  times,  if  necessary.  The  method  is  highly  recommended  in  hemor- 
rhage from  uterine  atony,  and  that  due  to  fibroma  (cited  from  Monod,  Montreal 
Med.  Jour.,  1905,  vol.  34,  p.  22). 

Cold  Applications. — In  cases  where  excessive  hemorrhage  must  be 
stopped  at  once,  the  application  of  cold  may  be  tried  by  placing  an  ice-bag 
over  the  lower  abdomen  and  another  over  the  lumbo-sacral  region.  This  is 
not,  however,  a  mode  of  treatment  which  is  often  advisable,  as  patients  suffer- 
ing from  loss  of  blood  usually  require  the  stimulating  effect  of  heat. 

Electricity. — The  treatment  of  uterine  hemorrhage  by  electricity,  much 
advocated  some  years  ago,  has  now  fallen  somewhat  into  disuse.  The  results 
from  it,  however,  were  often  favorable,  and  there  seems  no  doubt  that  it  is 
of  service  in  a  good  many  cases  and  may  obviate  the  necessity  for  a  radical 
operation. 

The  application  is  made  by  means  of  a  platinum  electrode,  with  a  movable 
insulating  sheath.  The  electrode  is  j)assed  up  to  the  fundus  of  the  uterus, 
while  the  insulating  sheath  is  adjusted  so  as  to  reach  just  beyond  the  internal 
OS.  As  the  bleeding  comes  from  the  body  of  the  uterus,  it  is  absolutely  neces- 
sary to  see  that  the  current  affects  the  body  of  the  uterus  and  not  the  cervix. 
Moreover,  strong  currents  cause  stenosis  of  the  cervical  canal.  A  large  clay 
pad  is  placed  on  the  wall  of  the  abdomen,  just  above  the  pubes,  and  connected 
to  the  negative  pole,  while  the  intra-uterine  electrode  is  connected  to  the  positive 
pole.  At  the  first  application,  only  a  mild  current  should  be  used,  not  more 
than  twenty  milliamperes ;  subsequently,  it  can  be  slowly  raised  until  the  gal- 
vanometer indicates  thirty-five  to  fifty  milliamperes.  This  is  kept  up  for  from 
ten  to  fifteen  minutes.  The  patient  need  not  stay  in  bed  during  the  progress 
of  the  treatment,  and,  except  in  extreme  cases,  she  can  come  to  the  physician's 
office  to  receive  it. 

The  applications  are  made  twice  a  week.  An  antiseptic  vaginal  douche 
should  be  used  every  morning  and  evening.  The  electrode  must,  of  course, 
be  absolutely  clean  and  should  be  placed  in  an  antiseptic  solution  like  any  other 


188  MENOKRIIAGIA    AND    METKOKEHAGIA.       EXTRA-UTEEINE    PKEGNANCY. 

instrument  before  being  used.  The  number  of  applications  will  vary  according 
to  the  severity  of  the  case.  Half  the  number  required  to  reduce  the  amount 
of  blood  lost  to  normal  proportions  must  be  given  to  produce  permanent  relief. 
The  treatment  is  suspended  for  a  week  during  menstruation,  but  if  the  flow 
has  not  ceased  at  the  end  of  that  time,  it  is  resumed.  In  some  cases,  where 
there  is  an  incessant  flow,  there  may  be  some  difficulty  in  knowing  exactly 
what  is  the  proper  date  for  menstruation,  but  by  closely  questioning  the  patient 
it  will  generally  be  found  that  in  one  week  out  of  every  four  the  loss  is 
greater  than  at  any  other  time,  and  this  may  be  taken  as  the  normal  time  for 
menstruation.  As  a  rule,  no  improvement  begins  until  several  applications 
have  been  made,  and  then  the  flow  diminishes  rapidly.  With  a  current  of 
twenty  milliamperes,  properly  applied  and  slowly  raised,  the  patient  feela 
little,  if  any  pain.  The  sensitiveness  of  the  uterus,  which  is  present  at  first, 
usually  goes  off  after  the  first  two  or  three  applications  (J.  E.  Parsons, 
Lancet,  1901,  vol.  1,  p.  547). 

Intra-uterine  Applications. — -The  application  of  caustics  to 
the  interior  of  the  uterus  during  the  intermenstrual  periods  is  often  of  great 
service  in  controlling  uterine  hemorrhage,  and  of  these  caustics  nitric  acid 
is  the  best.  Before  using  it  the  vagina  must  be  carefully  protected  with  gauze 
packed  around  the  cervix.  It  is  best  to  use  a  cylindrical  speculum,  which  fits 
snugly  around  the  cervix,  and  pass  up  the  fuming  nitric  acid  on  a  pledget  of 
cotton  by  means  of  an  applicator  to  the  fundus.  Great  care  must  be  taken  to 
avoid  any  excess  of  the  acid,  and  the  applicator  must  be  immediately  withdrawn. 

Surgical  Measures. — Operative  procedures  are  far  more  often  indicated  in 
the  treatment  of  menorrhagia  and  metrorrhagia  than  in  dysmenorrhea  or  amen- 
orrhea,, for  many  cases  of  uterine  hemorrhage  are  due  to  grave  organic  disease 
which  requires  surgical  measures  for  its  relief ;  moreover,  the  effects  of  frequent 
or  prolonged  loss  of  blood  upon  the  general  health  is  serious  enough  in  itself 
to  call  for  operative  interference  in  some  cases.  The  only  operation  for  the 
relief  of  uterine  hemorrhage  which  comes  within  the  scope  of  this  work  is 
curettage  of  the  endometrium.  This  is  a  simple  measure,  easily  per- 
formed, and  giving  excellent  results  in  a  large  number  of  cases,  provided  care 
is  exercised  in  the  selection  of  suitable  cases  and  in  the  performance  of  the 
operation.  It  frequently  happens  that  the  general  practitioner  is  called  upon 
to  perform  it  for  the  relief  of  uterine  hemorrhage,  and  also  for  the  purpose  of 
ascertaining  the  nature  of  the  disease  present  from  an  examination  of  the 
scrapings.  Whenever  the  general  practitioner  discovers,  or  has  reason  to  sus- 
j)ect  that  his  patient  is  suffering  from  malignant  disease  of  any  kind, 
it  is  his  duty  to  refer  her  at  once  to  a  specialist,  no  matter  what  may  be  the 
inconvenience  or  discomfort  to  her  or  her  relatives,  nor  how  plausible  the  rea- 
sons for  delay.  Fibroid  tumors,  also,  in  some  cases,  demand  radical  meas- 
ures for  their  relief,  but  there  are  many  cases  of  uterine  hemorrhage  associated 
with  abnormal  conditions  of  the  endometrium,  such  as  retained  products 
of    conception,    endometrial    hypertrophy,    endometritis,    submu- 


SURGICAL    TREATMENT    OF    UTERINE    HEMORRHAGE.  189 

cons  fibroids,  or  polypi,  in  \v]ii(']i  curettage  is  beneficial,  and  often 
effects  an  entire  cure,  if  not  at  once,  within  a  few  months,  and  possibly  after 
one  or  two  repetitions. 

The  operation  is  one  of  such  simplicity  that  its  performance  is  quite  within 
the  province  of  the  general  practitioner,  under  due  precautions,  and  therefore 
I  give  a  description  of  it  in  detail. 

Method  of  Curettage. — The  patient  is  prepared  and  cleansed,  and 
the  uterus  dilated  according  to  the  directions  given  for  dilatation  in  Chapter 
IV  (see  p.  122).  The  serrated,  sharp,  perforated  spoon  curette  (see  Fig.  52, 
p.  123),  poised  between  the  thumb  and  the  first  and  second  fingers,  is  then  easily 
introduced  into  the  dilated  canal.  The  whole  inner  surface  of  the  uterine  cavity 
from  the  fundus  to  the  cervix  is  next  carefully  scraped,  the  superficial  portion 
of  its  lining  membrane  being  removed  in  strips  and  short  pieces.  The  healthy 
basis  is  recognized  by  the  greater  resistance  and  by  a  slight  grating  sensation 
communicated  to  the  fingers.  The  separated  lining  membrane  is  expelled 
through  the  cervix  by  means  of  a  series  of  intermittent  contractions  and  the 
discharge  may  also  be  assisted  by  using  the  curette  to  scrape  it  out.  The 
hemorrhage  from  this  operation  is  never  sufficiently  severe  to  call  for  meas- 
ures to  control  it.  Some  persons  are  in  the  habit  of  introducing  gauze  into 
the  uterine  cavity,  but  it  has  never  been  my  custom.  The  patient  should  be 
kept  in  bed  for  from  three  days  to  a  week. 

Before  I  leave  the  subject  I  should  like  to  say  a  word  of  caution  in  regard 
to  the  danger  which  accompanies  curettage,  if  it  is  not  attended  by  the  same 
care  and  vigilance  practiced  in  every  surgical  procedure,  and  especially  those 
requiring  an  anesthetic. 

If  the  uterus  is  soft  or  the  condition  of  the  body  wall  pulpy  and  like  wet 
blotting  paper  (a  condition  not  to  be  recognized  by  any  digital  examination) 
then  the  curette  or  the  sound  may  pass  directly  through  the  uterine  wall  into 
the  abdominal  cavity,  and,  in  a  septic  case,  set  up  a  virulent  peritonitis.  In 
order  to  avoid  this  contingency,  the  operator  must  guard  against  using  much 
force,  the  curette  must  be  handled  with  the  greatest  gentleness  and  should 
never  be  pushed  against  the  uterine  wall.  If  the  instrument  should  perforate 
the  wall,  it  must  not  be  reintroduced ;  a  drain  should  be  inserted,  and  the 
patient  put  to  bed  and  watched.  If  the  case  is  known  to  be  septic,  and  the 
curette  passes  through  the  uterus,  the  abdomen  should  be  immediately  opened, 
the  area  excised,  and  the  opening  closed  with  catgut. 

W.  Hessert  (Amer.  Jour.  Ohst.,  1905,  vol.  51,  p.  26)  has  collected  from 
the  literature  a  number  of  cases  in  which  the  uterus  has  been  perforated  during 
curettage  and  gives  the  following  general  principles  which  should  be  observed 
in  order  to  avoid  such  an  accident: 

(1)  Make  an  accurate  pelvic  diagnosis,  as  to  size,  position, 
mobility,  and  consistency  of  the  organ.  Determine  the  presence  or 
absence  of  tumors  upon  or  within  the  organ.  Observe,  if  possible,  its 
contractility.     Determine  the   condition   of   the    adnexa   and  the  possi- 


190  MENORRHAGIA    AND    METRORRHAGIA.       EXTRA-tTTERlNE    PREGNANCY. 

bility  of  pus  tubes,  ovarian  tumors,  pelvic  abscesses,  and  the  like.     In  other 
words,  get  as  clear  a  picture  as  possible  of  the  pelvic  organs. 

(2)  In  curetting  post-partum,  bear  in  mind  the  possible  extreme  fria- 
bility of  the  uterus.  The  cervix  should  be  amply  dilated -to  admit  the 
finger.  The  direction  of  the  cervical  canal  and  the  uterine  cavity  should  be 
accurately  determined  l)y  means  of  a  graduated  sound.  The  question  of  angu- 
lation backwards  or  forwards  should  be  known  before  introducing  dilators^ 
especially  Goodell's.  Disregard  of  this  precaution  has  been  the  cause  of  most 
perforations  made  with  Goodell's  dilators.  Avoid  the  ratchet  and  screw,  but 
use  the  hands  in  dilating  carefully.  Dilate  slowly,  so  as  not  to  split  the  cervix, 
meanwhile  turning  the  instrument  around  to  all  points  of  the  circle. 

(3)  A  sharp  curette  is  best  for  the  purpose.  Be  careful  in  the  use 
of  the  placental  forceps  in  pulling  down  anything  which  may  be  felt  in  the 
uterine  cavity,  as  it  may  be  omentum  or  gut.  ISTever  use  a  volsella  forceps 
for  this  purpose. 

(4)  Except  in  the  presence  of  septic  endometritis  the  use  of  the  irrigator 
is  generally  superfluous.  If  it  is  used,  a  non-toxic  solution,  such  as  boric  acid, 
should  be  employed.  Avoid  strong  solutions,  such  as  sublimate.  If  there  is 
the  least  suspicion  of  perforation,  omit  all  irrigation.  The  injection  of  caustics, 
such  as  liquor  ferri  chloridi,  tincture  of  iodine,  chloride  of  zinc,  etc,  is  not 
without  danger,  and  should  be  employed  only  where  there  are  special  indications. 

Any  condition  causing  atrophy  of  the  uterus  is  one  which,  by  ren- 
dering the  uterus  unduly  friable,  is  likely  to  result  in  perforation.  The  local 
conditions  associated  with  uterine  atrophy  are:  carcinoma,  myoma,  pel- 
vic   tuberculosis,    pelvic    abscess,    recent    abortion,    and  others. 

The  general  or  constitutional  conditions  accompanied  by  atrophy  are 
leukemia,  diabetes,  nephritis,  Addison's  disease,  tuberculosis, 
pernicious    anemia,    and  the    acute    infectious    diseases. 

Curettage  for  Remnants  of  Abortion. — Curettage  for  the  removal 
of  a  dead  ovum  or  the  remains  of  an  incomplete  abortion  requires 
a  few  words  of  special  direction,  because  of  the  danger  arising  from  the  readi- 
ness with  which  sepsis  may  invade  the  upper  genital  tract  in  the  presence  of 
either  of  these  conditions.  In  cases  which  are  already  septic,  the  avoidance 
of  a  general  infection  and  the  safety  of  the  patient  depend  upon  the  complete 
removal  of  the  ovum  and  the  establishment  of  artificial  drainage  through  the 
dilated  cervix.  There  is  no  way  by  which  a  septic  uterus  can  be  thoroughly 
disinfected.  Cases  which  are  not  septic  will  not  become  so,  if  the  operation  is 
aseptically  performed  and  the  aseptic  conditions  maintained  afterwards.  In 
curettage  shortly  after  an  abortion  has  taken  place,  the  anterior  cervical  lip  is 
caught  with  a  tenaculum  forceps,  a  blunt  spoon  curette  is  introduced,  and  used 
with  gentle  force  over  the  whole  surface  of  the  uterus,  loosening  and  bringing 
down  the  membranes,  which  begin  to  pour  out  of  the  os.  Undue  force  must 
not  be  used,  lest  the  curette  perforate  the  softened  uterine  wall  and  pass  into 
the  abdominal  cavity,  exposing  the  j)atient  to  the  imminent  risk  of  a  septic 


CURETTAGE    FOR    REMNANTS    OF    ABORTION.  191 

peritonitis.  I  have  known  a  case  in  which  curettage  was  performed  two  and 
a  half  months  after  an  early  abortion  (three  weeks)  in  which  several  blocks 
of  firm  whitish  material  were  removed  from  one  side  of  the  uterus,  when, 
without  the  use  of  any  force  whatever,  the  curette  suddenly  perforated  the 
fundus.  After  loosening  the  membranes  with  the  curette  a  pair  of  fenestrated 
placental  forcej)S  is  inserted,  which  brings  away  the  placenta,  the  decidua,  and 
the  fetus,  if  it  has  not  been  previously  expelled,  whole  or  in  pieces.  When 
the  canal  is  large  enough,  as  is  usually  the  case  in  a  miscarriage  after  the 
third  month  of  pregnancy,  the  index  finger,  well  sterilized,  should  be  inserted 
and  the  whole  interior  of  the  womb  palpated.  Unsuspected  pieces  of  tissue 
may  be  found  clinging  to  it,  especially  in  the  placental  area.  These  can  be  freed 
by  the  palmar  surface  of  the  finger,  assisted  by  the  external  hand  acting  through 
the  abdominal  walls  and  affording  a  point  of  resistance.  The  uterine  wall,  thus 
bared  in  places,  feels  almost  as  thin  as  paper  and  must  be  gently  handled. 
When  curettage  is  difficult  and  uncertain,  the  entire  separation  of  the  remains 
of  the  ovum  may  be  effected  by  the  finger  alone,  assisted  by  the  hand  making 
counter-pressure  through  the  abdominal  walls.  The  finger-nails  must  never 
be  used  to  scrape  off  tissue  from  the  uterine  walls,  as  such  a  practice  would 
often  introduce  sepsis,  and  if  the  case  is  already  septic,  the  operator  would  be 
sure  to  carry  infection  away  with  him  to  inoculate  other  patients.  Irrigation 
of  the  uterus  after  curettage  for  abortion  is  not  necessary,  unless  the  contents 
are  septic,  when  the  cavity  must  be  repeatedly  washed  out  with  a  warm  boric- 
acid  solution,  introduced  by  means  of  a  curved  glass  douche  nozzle,  the  blunt 
end  of  the  nozzle  being  used  to  aid  in  detaching  clots  and  small  particles  of 
debris.  The  uterus  may  be  drained  for  forty-eight  hours  by  packing  its  cavity 
loosely  with  gauze,  the  ends  of  which  are  allowed  to  hang  out  of  the  cervix  into 
the  vagina ;  my  own  practice,  however,  is  simply  to  place  a  loose  pack  in  the 
vagina,  which  is  renewed  every  twenty-four  hours.  Patients  should  be  kept 
in  bed  for  two  weeks  or  longer  after  curettage  for  abortion,  in  order  to  allow 
involution  of  the  uterus  to  take  place.  Care  of  the  patient  is  just  as  important 
at  this  time  as  in  the  puerperium  after  a  normal  labor. 

Examination  of  Scrapings  Removed  by  Curettage. — The 
scrapings  from  the  endometrium  should  always  be  examined,  for  they  afford 
reliable  evidence  as  to  the  nature  of  the  condition  underlying  the  hemorrhage. 
The  following  conditions  should  always  be  looked  for : 

ISTormal  uterine  mucosa. 

Acute  endometritis. 

Chronic  endometritis. 

Decidual  endometritis. 

Mucous  polypi. 

Remnants  of  abortion. 

Tuberculosis  of  the  tubes  and  ovaries. 

Carcinoma  of  the  uterus,  body  and  cervix. 

Sarcoma  of  the  uterus,  body  and  cervix. 


192  MENOERTtAGiA    AND    METROHEHAGIA.       EXTEA-UTEEINE    PEEGNANCT. 

The  fovinaliu  method  of  preparation,  fire^l  introduced  by  Dr.  T.  S.  CuUen 
{Johns  Uopl'ins  IIosp.  Bull.,  April,  1895),  and  later  by  Pick,  is  the  best,  as 
it  obviates  the  tedious  delay  incident  to  the  older  methods  of  preparation  and 
permits  a  diagnosis  to  be  made,  in  case  of  necessity,  with  a  competent  pathol- 
ogist at  hand,  within  tifteen  minntes. 

The  procedure  is  as  follows: 

(a)  Place  frozen  sections  of  the  fresh  tissue  in  a  five  per  cent  aqueous  solu- 
tion of  formalin  for  from  three  to  five  minutes. 

(b)  Immerse  in  fifty  per  cent  alcohol  for  three  minutes. 

(c)  Place  in  absolute  alcohol  one  minute. 

(d)  Wash  in  water. 

(e)  Stain  in  hematoxylin  for  two  minutes. 

(f)  Decolorize  in  acid  alcohol. 

(g)  Rinse  in  water,  to  which  has  been  added  two  or  three  drops  of  am- 
monia, which  rapidly  brings  back  the  characteristic  hematoxylin  color. 

(h)   Stain  with  eosin. 

(i)   Transfer  to  ninety-five  per  cent  alcohol. 

(j)  Pass  through  absolute  alcohol,  creosote,  or  oil  of  olives,  and  mount  in 
Canada  balsam. 

When  it  is  not  of  the  first  importance  to  save  time,  finer  sections  may  be 
obtained  by  CuUen's  second  method,  in  which  the  tissues  are  first  hardened  in 
formalin,  as  follows:  The  sections  are  placed  immediately  in  a  ten  per  cent 
solution  of  formalin,  kept  in  small  bottles  always  at  hand.  Within  three  or 
four  hours  they  are  sufficiently  hardened  to  cut  readily,  when  frozen  sections 
are  made  and  left  in  a  fifty  per  cent  solution  of  alcohol  for  three  minutes,  after 
which  the  succeeding  steps  are  taken  as  before  described. 

Curetted  specimens  must  always  be  placed  in  a  bottle  by  themselves  and 
labelled  at  once  with  the  patient's  name  and  the  date.  When  the  sections  are 
cut,  no  similar  open  dishes  containing  other  specimens  should  be  lying  about, 
nor  should  sections  under  consideration  be  passed  through  the  fluids  together 
with  other  sections,  in  order  to  avoid  the  terrible  mistake  of  confusing  the  two 
cases  and  so  leading  to  erroneous  conclusions.  Serious  mistakes  have  followed 
the  mixing  of  specimens, 

jSTormal  Uterine  Mucosa. — The  standard  for  comparison  from  all 
curetted  specimens  is  the  normal  uterine  mucosa ;  this  presents,  microscopically, 
an  even  surface  covered  by  a  single  layer  of  cylindrical  ciliated  epithelium. 
The  glands  are  round  or  oval-shaped  on  cross  section,  and  in  a  few  places  they 
may  be  seen  to  open  on  the  surface.  They  are  usually  equidistant  and  are  lined 
with  one  layer  of  cylindrical  ciliated  epithelium.  An  occasional  bifurcation  is 
seen  in  the  deeper  layers  of  the  gland.  Lying  between  the  glands  is  found  the 
stroma  of  the  mucosa  or  so-called  lymphoid  tissue.  .  The  cells,  however,  are 
much  larger,  and  on  close  examination  bear  no  resemblance  to  lymphoid  tissue ; 
the  nuclei  of  the  stroma  cells  are  oval,  vesicular,  and  appear  to  best  advantage 
in  specimens  hardened  in  Miiller's  fluid.     The  arteries  of  the  stroma  are  usually 


CONSTITUTIONAL    TREATMENT    OF    UTERINE    IIEMOKEHAGE.  193 

found  in  small  bunches ;  the  veins  are  large,  single,  and  thin-walled.  The  blood 
in  the  veins  is  separated  from  the  stroma  cells  by  one  layer  of  endothelium.  The 
line  of  demarcation  between  the  mucosa  and  the  muscle  is  usually  well-defined ; 
occasionally,  however,  a  gland  penetrates  the  muscle  for  some  depth,  when  it 
is  invariably  accompanied  by  a  considerable  amount  of  stroma.  This  dipping 
of  a  gland  in  the  muscularis  must  not  be  mistaken  for  a  pathological  condition. 

The  appearance  suggestive  of  malignant  disease,  whether  carcinoma 
or  sarcoma,  will  he  found  described  in  Chapter  XXI  (see  p.  527).  The 
other  conditions  in  regard  to  which  conclusions  can  he  drawn  from  the  exam- 
ination of  curettings  will  be  found  under  their  separate  headings  in  the  diag- 
nosis of  monorrhagia. 

Constitutional  Measures. — Under  this  head  come  those  measures  which  may 
be  employed  to  remove  the  constitutional  causes  underlying  certain  cases  of 
uterine  hemorrhage.  Cardiac  and  hepatic  disease  are  both  sometimes 
associated  with  monorrhagia,  or  metrorrhagia,  or  both,  and  when  this  is  the  case 
the  relief  of  the  underlying  cause  will  relieve  the  local  hemorrhage.  In  cases 
of  cardiac  derangement,  digitalis  in  tonic  doses,  ten  to  fifteen  drops,  three 
times  daily,  is  frequently  of  great  benefit.  After  the  heart's  action  has  been 
improved,  strychnin  and  arsenic  are  of  value.  A  marked  rheumatic 
diathesis  must  receive  appropriate  treatment  as  well  as  anemia  or  scurvy. 
Tor  hepatic  derangements,  calomel  is  usually  indicated,  with  attention 
to  diet,  exercise,  and  general  hygienic  measures  of  every  kind. 

General  Suggestions. — In  conclusion,  the  following  suggestions  may  be  made 
as  to  the  treatment  of  uterine  hemorrhage  in  general: 

If  the  hemorrhage  is  due  to  the  retained  products  of  conception, 
to  hypertrophy  of  the  endometrium,  endometrial  polypi,  endo- 
metritis (acute  or  chronic),  submucous  myomata,  or  decidual  en- 
dometritis, curettage  is  certainly  indicated,  and  will  afford  relief  in  a  large 
proportion  of  cases.  It  is  better  to  resort  to  this  measure  as  soon  as  the  diag- 
nosis is  clear  than  to  wait  to  try  a  long  course  of  topical  treatments  which 
rarely,  if  ever,  do  any  good.  It  must  always  be  remembered  that  it  may  be 
necessary  to  repeat  the  curettage  several  times.  Should  curettage  of  the  endo- 
metrium reveal  the  presence  of  can'cer,  sarcoma,  chorio-epithelioma 
or  extra-uterine  pregnancy,  the  patient  must  be  at  once  referred  to  a 
specialist,  no  matter  what  difficulties,  real  or  imaginary,  are  put  in  the  way  of 
such  a  course.  Cases  of  subinvolution  or  inversion  of  the  uterus, 
interstitial  or  sub-peritoneal  myomata,  sclerosis  of  the  uterine 
vessels,  or  corpus  luteum  cysts,  should  also  be  sent  to  a  specialist, 
although  there  is  not  the  same  pressing  need  for  haste  as  in  the  cases  mentioned 
above.  Fibroid  tumors  giving  rise  to  uterine  hemorrhage  must  be  differ- 
ently'treated  according  to  the  indications  in  each  individual  case;  these  are 
discussed  at  length  in  Chapter  XX.  Uterine  hemorrhage  due  to  constitu- 
tional or  vascularcauses  is  distinctly  the  work  of  the  general  practi- 
tioner and  must  receive  his  most  careful  attention.  The  indications  for  treat- 
14 


194  MENORRHAGIA    AND    METRORRHAGIA.       EXTRA-UTERINE    PREGNANCY, 

ment  in  such  cases  belong  to  the  works  on  general  medicine  in  whicli  the 
conditions  underlying  the  uterine  hemorrhage  are  discussed.  It  is  greatly  to 
be  desired  that  physicians  in  general  should  make  this  class  of  patients  the  object 
of  their  careful  study,  for  they  are  more  likely  to  be  benefited  by  the  attention 
of  the  general  practitioner  than  that  of  the  specialist. 

EXTRA-UTERINE    PREGNANCY. 

History. — Few  subjects  in  the  whole  range  of  his  ^^ractice  excite  so  lively  an 
interest  in  the  general  practitioner  as  extra-uterine  pregnancy.  Of  all 
the  mysterious  processes  of  life,  the  most  mysterious  is  that  an  ovum  can  become 
fertilized  and  gTow  on  ground  foreign  to  its  normal  development.  Xatural 
interest  in  this  extraordinary  phenomenon  is  great  and  it  is  enhanced  by  the 
fateful  possibilities  of  the  situation  as  well  as  the  tragic  outcome  which  may, 
at  any  moment,  determine  a  doubtful  diagnosis  and  rob  the  poor  victim  of  life. 
For  these  reasons,  and  because  such  cases  fall,  in  the  first  stage,  into  the  hands 
of  the  family  physician  in  the  majority  of  cases,  it  is  important  that  he  should 
know  something  in  detail  of  the  course  of  such  pregnancies  not  interrupted  by 
the  surgeon ;  of  the  methods  of  their  diagnosis ;  and  of  the  j)i'oper  means  for 
their  relief. 

Extra-uterine  pregnancy  was  once  thought  to  be  extremely  rare,  but  it  is 
now  known  to  be  comparatively  common.  There  are  few  jDhysicians  who  have 
been  ten  years  in  practice  without  seeing  at  least  several  instances,  sometimes 
in  a  single  year.  Veit  has  shown  that  many  of  those  cases  of  irregular 
menstruation  associated  with  colic,  which  pass  off  without  special  treatment, 
or  with  a  little  watchful  attention  on  the  part  of  the  physician,  are,  in 
reality,  a  relatively  mild  ending  to  an  extra-uterine  pregnancy.  For  this 
reason,  as  we  can  readily  see,  all  deviations  from  the  norm  during  pregnancy 
ouglit  to  excite  the  liveliest  attention  on  the  part  of  the  responsible  medical 
attendant. 

It  may  be  said  then  that  extra-uterine  pregnancy  in  its  early  stages  belongs 
to  the  general  practitioner ;  as  soon  as  the  diagnosis  is  made,  however,  the 
case  should  at  once,  as  a  matter  of  propriety,  be  transferred  to  the  domain 
of  the  surgeon.  If  it  were  possible,  it  would  be  best  for  the  patients  if  all 
cases  could  be  classified  as  surgical  from  the  outset.  As  to  the  promptitude 
with  which  this  transfer  is  effected  from  the  purely  medical  to  the  purely 
surgical  domain,  it  is  interesting  to  note  that  the  experience  of  one  case  is 
sufficient  to  quicken  the  diagnostic  powers  to  such  a  degTee  that  subsequent 
cases  are  detected  much  earlier,  and  in  consequence  subjected  to  a  relatively 
earlier  appropriate  radical  treatment,  which  is  always  operative  and  extirpative. 
In  order  to  grasp  his  subject  properly,  the  general  practitioner  must  be  familiar 
with  the  causes  of  extra-uterine  pregnancy,  with  its  course  if  left  alone,  and 
with  the  various  diagnostic  signs,  which  we  will  now  take  up. 

An  extra-uterine  ovum  may  lodge  in  any  one  of  the  six  places  indicated  in 


ETIOLOGY    OF    EXTEA-TJTEEINE    PREGNANCY. 


195 


Fig.  65. — Various  Sites  of  Implantation  of 
THE  Ovum  in  Extra-uterine  Pregnanct. 
1,  ovarian  pregnancy;  2,  implantation  upon 
the  tubo-ovarian  fimbriae;  3,  implantation 
within  the  fimbriated  extremity  of  the  uter- 
ine tube ;  4,  attachment  of  the  ovum  in  the 
ampulla;  5,  isthmial  attachment;  6,  inter- 
stitial implantation. 


Kgnre  65,  proceeding  from  within  outwards:  (1)  in  tlie  ovary;  (2)  in  the 
tubo-ovarian  iinihria;  (3)  just  within  the  grasp  of  the  tubal  fimbria;  (4)  in 
the  ampulla;  (5)  in  the  isthmial  or  narrow  part  of  the  tube;  (6)  or,  finally, 
in  the  interstitial  portion  of  the  tube,  where  it  traverses  the  uterine  wall.  The 
commonest  of  these  sites 
is  the  ampulla  implan- 
tation and  the  next  com- 
monest the  isthmial. 
The  interstitial  form  is 
rare  and  of  the  ovarian 
only  a  few  examples  have 
ever  been  seen. 

Etiology. — There  is 
no  one  cause  which  can 
be  said  to  be  commonly 
operative  in  extra-uter- 
ine pregnancy,  and  this 
is  only  what  we  might 
reasonably  expect  from 
our  knowledge  of  pregnancy  in  its  early  stages.  The  spermatozoa  meet  and 
fructify  the  ovum  at  or  near  the  ovary,  and  it  is  the  function  of  the  uter- 
ine tubes,  which  have  afforded  the  spermatozoa  an  avenue  of  access  from 
the  uterus  to  the  ovum,  to  transmit  the  ovum  in  turn  to  its  proper  resting 
place  in  the  uterus.  The  small  spermatozoa  travel  up  the  uterus  and  down  the 
tube  by  their  own  active  propulsive  movements,  while  the  larger  ovum  must 
be  swept  towards  the  uterus,  through  the  ampulla  of  the  tube,  p-ast  all  the  tubal 
folds,  into  the  narrow  isthmus,  and  so  through  the  interstitial  portion  of  the 
tube  into  the  uterus,  where  it  commonly  lodges  near  one  cornn. 

An  extra-uterine  pregnancy  is  brought  about  by  any  cause  whatever  which 
tends  to  hold  the  ovum  back  until  it  is  too  large  to  travel  further  down  the 
constantly  narrowing  tube.  Let  us  note  categorically,  and  with  but  brief  dis- 
cussion, what  these  efficient  causes  may  be: 

1.  Adhesions  may  bind  the  tube  down,  or  bands  may  cut 
across  it,  so  as  to  produce  an  ileus,  as  it  were,  preventing  the 
propulsion  of  the  ovum,  while  not  necessarily  hindering  the 
spontaneous  movements  of  the  spermatozoa.  This  is  the  oldest  view 
and  undoubtedly  the  obstruction  operates  in  many  cases,  though  it  must  be 
borne  in  mind  that  many  of  the  adhesions  and  inflammatory  changes  seen  at 
an  operation  have  occurred  after  the  pregnancy  and  not  before  it;  therefore 
they  cannot  be  reckoned  among  the  causes  in  a  particular  case. 

2.  Tumors  of  the  tubal  mucosa  have  been  noted  as  plugging 
the  lumen  of  the  tube,  accounting  for  the  obstruction  in  a  few  rare  in- 
stances. Fibroid  tumors  at  the  uterine  cornu,  distorting  and  block- 
ing the  isthmial  portion  of  the  tube,  have  been  found  occasionally. 


196 


MENOKRHAGIA    AND    METROKRHAGIA.       EXTEA-UTEEINE    PREGNANCY. 


Fig.  66. — H.,  Church  Home,  January  23,  1903.  Pregnancy  in 
the  ampulla  in  which  a  striking  feature  is  the  presence  of  the 
cyst  lying  under  the  tubo-ovarian  fimbriEe.  Hemorrhage  to  the 
amount  of  about  1^  liters  into  the  peritoneal  cavity.  Operation. 
Recovery.     Nine-tenths  natural  size.      (Case  of  T.  S.  Cullen.) 


6,  A   long,    narrow,    winding   tube   of  tlie 


3.  A  tubo-ovarian  cyst,  by  distorting  the  tube,  may  sometimes  act 
as  a  cause.     (See  Fig.  66.) 

4.  Inflammation    of   the    tubal   mucosa    by    which    its    cilia    are 
destroyed,   has   been  noted   also,   though,   as   Bumm  remarks,   this   view   pre- 
supposes the  presence  of 
enough  cilia  to  carry  the 
ovum  to  its  lodging  place. 

5.  Diverticula  in 
the  tube  sometimes 
serve  to  catch  and 
lodge  the  ovum,  wrap- 
ping it  around  as  it 
were.  These  diverticula, 
however,  are  so  commonly 
found  in  normal  tubes, 
that  it  is  evident  some 
other  cause  must  first  act 
to  retard  the  progress  of 
the  ovum  before  it  slips 
into  the  diverticulum, 
fetal  type  is  undoubt- 
edly the  cause  in  some  cases. 

7.  The  migration  of  the  ovum  into  an  atretic  tube.  The  sper- 
matozoa enter  by  a  patulous  tube  and  fertilize  the  ovum,  Avhich  then  passes 
over  into  the  opposite  atretic  tube.     (See  Fig.  67.) 

8.  Many  extra-uterine  ova  contain  monstrous  fetuses  ;  in  such 
cases  the  size  of  the  ovum  must  act  to  hinder  its  advancement  and  so  cause  a 
tubal  implantation. 

It  will  be  seen  from  these  facts  that  not  one,  but  many  causes  are  continu- 
ally acting  to  make  extra-uterine  pregnancy  a  common  ailment  in  every  com- 
munity. 

The  determination  of  the  cause  in  any  given  case  can  only  be  made,  if  at 
all,  at  the  operating  table,  or  rather  after  the  operation  in  the  pathological 
laboratory.  Even  then,  with  every  possible  advantage  afforded  by  clinical  his- 
tory, a  careful  operation,  and  the  benefit  of  numerous  microscopic  sections,  it 
is  often  impossible  to  say  why  the  extra-uterine  pregnancy  occurred. 

The  only  aid  the  practising  physician  can  derive  from  the  operation  is  the 
knowledge  derived  from  statistics  that  there  is  a  peculiar  liability  on  the  part 
of  those  women  who  have  had  one  extra-uterine  pregnancy  to  have  another.  All 
of  our  extra-uterine  pregnancy  cases  ought  therefore  to  be  watched  with  a 
peculiar  solicitude  lest  they  become  pregnant  again,  and  if  they  do  become 
pregnant,  lest  it  turn  out  to  be  an  ectopic  growth. 

The  accidents  which  may  happen  to  the  ovum  in  an  extra-uterine  pregnancy 
are  many.     It  practically  always  ends  its  existence  by  a  violent  death,  caused  by 


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198 


MENOEEHAGIA    AISTD    METEOEEHAGIA.       EXTEA-UTEEIXE    PEEGNANCY. 


the  rupture  of  its  containing  sac   (see  Fig.   68),  or  bj  a  tubal  abortion,  by 

which  it  slips  out  of  the  sac  into  the  peritoneal  cavity.     (See  Figs.  69  and  70.) 

Sometimes  the  ovum,  encapsulated  in  a  surrounding  hemorrhage,  deprived 

of  its  nutrition,  dies,  and  shrinks  into  an  innocuous  hard  nodule  in  the  tube; 

this  termination  is  unusual. 
Only  in  the  rarest  instances, 
once  out  of  thousands  of 
cases  it  may  be,  does  the 
extra-uterine  fetus  go  on 
developing  to  term. 

Then  false  labor  pains 
come  on,  and  if  the  condi- 
tion is  not  recogTiized  and 
the  babe  removed  by  an  ab- 
dominal section,  it  dies  and 


becomes  mummified  in  the 
midst   of   the   intestines,   to 


undergo  changes  resembling 


Fig.  68.— R.  W.  U.,  Aror.ST  17,  1903.     Gi-x.  No.  10672.     The 
iliGHT  Uterixe  Tube  is  seen  to  be  the  Seat  of  ax  Ex- 

TRA-UTERIX-E      PrEGXAXCY,     -milCH     HAS      RuPTURED,      DlS- 

CHARGix'G    Blood    ixto    the    Peritoxeal   Cavitt.     The 
Seat  of  Rupture  is  Plugged  by  Clots  axd  Villi. 

adipocere  later  on;  or,  in- 
cased and  infiltrated  with  lime  salts,  to  form  a  lithopedion  or  stone  child. 
Although  the  fetus  is  apparently  thus  satisfactorily  disposed  of,  it  is  not  and 
never  can  become  a  safe  giiest,  as  long  as  it  is  harbored  in  the  body.     It  is  likely 


Fig.  69. — Extra-uterix'e  Pregx'axcy;  Tubal  Abortiox.  The  bleeding  is  checked  by  a  large  coagu- 
lum  distending  and  thinning  out  the  tube;  the  fimbriated  opening  is  greatly  distended,  but  the 
greater  diameter  of  the  clot  in  the  ampulla  prevents  its  escape.  Wall  of  tube  averages  1  mm.  in 
thickness.     Operation.      Recover^-.     Jtily  7,  1896.     Natural  size. 

at  any  time  to  cause  an  intestinal  obstruction  through  adhesions,  or  to  set  up 
an  inflammation  which  only  ends  when  it  has  been  discharged  bone  by  bone 
from  the  rectum,  the  bladder,  the  vagina,  or  through  the  abdominal  wall,  it 
may  be  years  afterwards. 


DIAGNOSIS    OF    EXTRA-UTEKINE    PBEGNANCT. 


199 


Diagnosis. — The  diagnosis  of  an  extra-uterine  pregnancy  in  the  early  months 
is  almost  always  made  after  the  rupture  of  the  sac;  it  is  not  difficult  to  make, 
if  the  striking  set  of  signs  which  I  will  enumerate  categorically,  with  brief 
annotations,  are  borne  in  mind. 

1.  There  has  been  a  cessation  of  menstruation,  perhaps  one  or 
two  periods,  or  the  patient  may  have  gone  but  a  few  days  or  a  week  over  the 
time. 

2.  Nausea  and  other  changes  which  the  patient  is  accustomed  to  as- 
sociate with  an  early  pregnancy  are  noted  as  the  weeks  pass  by. 


Fig.   70. — CVjaglum    Iik-Nld  ()i  i  — Showing  a  cast  of  the  tube  extending  up  into  the  isthmus.      On 

its  surface  lies  the  fetus.     Natural  size. 


3.  The  patient  thinks  she  is  pregnant,  but  is  inclined  to  believe 
there  is  something  wrong  or  unusual  with  this  particular  pregnancy. 

4.  Recurring    pains    in   one    side    are  often  noted. 

5.  A  sudden  attack  of  agonizing  pain  sometimes  constitutes  the 
first  symptom.  This  may  come  on  in  sleep,  but  it  is  apt  to  appear  during 
exertion,  as  while  sitting  in  the  closet,  or  at  work  reaching  or  lifting. 

6.  With  the  pain  comes  collapse  and  the  sudden  develop- 
ment   of   extreme    and    increasing    anemia. 

7.  Sighing,  gasping,  respiration  which  is  rapid  and  small 
mark  the  worst  cases. 

8.  If    the    patient    survives    her    first    attack,    she    suffers    at 


200  MENOEEHAGIA    AND    METKOEEHAGIA.       EXTEA-UTEEINE    PEEGXAISTCT. 

intervals    from    repeated    similar    ones,    with    irregular    uterine 
discharges. 

Objectively,  the  physician  sometimes  (but  not  always)  notes: 

1.  The    blue   or    cyanotic   vagina,    so  indicative  of  pregnancy. 

2.  An  enlarged  uterus,  as  big  as  a  two  months'  pregnancy,  rarely 
larger. 

3.  A  tumor,  at  the  side  of  or  behind  the  uterus  but  always 
more  or  less  one-sided,  which  is  peculiarly  sensitive  to  touch. 

■i.  If  the  sac  has  ruptured,  the  blood  poured  out  causes  the 
tumor  to  grow  rapidly,  increasing  with  each  successive  severe 
pain  and  coincident  hemorrhage.  Sometimes  the  lower  abdominal  wall 
shows  a  boss  as  big  as  a  fist.  To  the  vaginal  touch  the  tumor  feels  peculiarly 
boggy  and  lacks  the  well-defined  outline  of  other  tumors,  or  the  hardness  of  in- 
flammatory affections. 

If  there  is  no  rupture,  nor  escape  of  the  ovum  or  blood  through  the  fim- 
briae of  the  tube,  then  the  fetus  dies  and  the  sac  shrinks,  while  under  an  ob- 
servation extending  over  two  or  three  weeks.  This  is  a  rare  finding  and  ought 
never  to  be  waited  for.  The  breasts  show  milk  as  the  pregnancy  goes  on 
developing.  The  patient  often  declares  that  she  has  passed  a  shaggy  skin-like 
structure  (decidua),  or,  more  fortimately,  keeps  it  to  show  to  the  physician 
and  ask  his  opinion  as  to  its  nature.  The  decidua  may  come  away  in  shreds, 
or  it  may  be  found  only  on  curetting  the  uterus ;  this  should  always  be  done  in 
a  case  of  uncertainty.  The  finding  of  decidua,  or  the  passing  of  a 
decidual  cast  in  the  presence  of  a  uterine  tumor,  practically 
settles    the    diagnosis. 

The  anemia  is  often  so  profound  that  the  patient  is  almost  undistinguish- 
able  from  her  own  bed  sheets.  The  pulse  is  tiny  and  thready,  or  may  even  have 
vanished  at  the  wrist.     There  is  little  or  no  fever  until  the  clots  become  infected. 

Xot  all  of  these  signs  must  be  expected  in  any  one  case ;  indeed,  the  picture 
is  rarely  a  complete  one.  A  few  are  sufiicient  for  practical  purposes,  of  which 
the  most  important  are : 

Presumptive  evidence  of  pregnancy. 
A  sensitive  tumor  at  the  side  of  the  uterus. 
The  fact  that  the  uterus  contains  no  ovum. 
Attacks  of  severe  abdominal  pain. 

Four  conditions   are  liable  to  be  confused  with  extra-uterine   pregnancy, 

namely : 

[N^ormal  pregnancy. 

An  ordinary  uterine  abortion. 

Salpingitis  and  pelvic  inflammatory  disease. 

Appendicitis. 


EXTEA-UTEKINE    PEEGNAISTCY    ANB    NORMAL    PKEGWAlSrCY.  201 

EXTRA-UTERINE    PREGNANCY    AND    NORMAL    PREGNANCY. 

It  is  sometimes  difficult  to  distinguish  between  an  extra-uterine  and  a  nor- 
mal pregnancy,  and  in  some  cases  it  may  not  be  possible  to  make  a  correct  diag- 
nosis at  once.  It  is  not,  of  course,  in  those  cases  of  extra-uterine  pregiiancy 
which  run  a  thundering  course,  where  the  patient  is  seized  with  an  agonizing 
pain,  falls  in  collapse  and  rapidly  becomes  anemic  while  engaged  in  common 
domestic  duties ;  it  is  not,  I  say,  in  these  cases,  but  in  the  more  quiescent 
ones,  that  a  mistaken  diagnosis  may  occur.  If  the  symptoms  are  of  only 
moderate  intensity,  the  physician  may  be  lulled  into  thinking  that  per- 
haps after  all  he  is  dealing  with  nothing  more  than  a  regular  pregnancy 
with  some  slight  deviations  from  the  normal.  In  every  case  where  there  is 
serious  doubt,  it  is  best  to  keep  the  patient  under  close  observation,  to  keep 
her  quiet  and  to  examine  more  than  once,  then,  if  the  doubt  is  not  cleared 
up,  her  bowels  should  be  well  emptied  and  a  thorough  examination  made  under 
complete  anesthesia. 

We  have  in  both  conditions  a  like  cessation  of  menstruation,  with  nausea, 
and  a  presumption  on  the  part  of  the  patient  that  she  is  pregnant.  A  local  exam- 
ination, too,  reveals  some  enlargement  of  the  uterus,  and  in  the  early  months  it 
may  often  be  difficult  to  say  whether  the  womb  is  just  large  enough  for  the 
period  of  pregnancy  or  not.  When  there  are  no  further  signs  than  these,  we 
cannot  even  suspect  an  extra-uterine  pregnancy.  In  order  to  arouse  suspicion 
there  must  enter  into  the  clinical  history  certain  added  elements:  (1)  severe 
pain  in  the  lower  abdomen,  (2)  a  repetition  of  such  attacks  of  pain,  (3)  the 
strong  suspicion  on  the  part  of  the  patient  that  all  is  not  right,  (4)  marked 
tenderness,  (5)  a  uterus  which  is  not  duly  developed  if  the  pregnancy  has 
gone  beyond  the  third  month,  (6)  a  lateral  tender  mass.  Often  the  free, 
repeated  vaginal,  bloody  discharges  leave  the  practitioner  in  no  doubt,  but 
that  if  the  case  is  one  of  a  uterine  pregnancy,  it  must  inevitably  terminate  in 
abortion.  He  will  then  feel  free  to  act  promptly  by  anesthetizing,  curetting  the 
uterus  and  making  a  careful  bimanual  examination  through  the  rectum,  in  this 
w^ay  clearing  up  the  diagnosis. 

The  task  of  deciding  between  the  two  conditions,  extra-uterine  and  intra- 
uterine, differs  materially  according  as  the  pregnancy  is  early  or  advanced. 
In  an  early  pregnancy  we  look  for  evidences  of  a  mass  at  the  side  of  the 
uterus  with  hemorrhage,  and  more  or  less  profound  systemic  disturbances  in« 
the  extra-uterine  condition,  as  contrasted  with  the  absence  of  any  mass  or  clots 
accumulated  in  the  pelvis,  with  a  uterus  lying  within  the  pelvis  which  is  more 
or  less  softened  and  enlarged  to  correspond  to  the  month  in  a  normal  preg- 
nancy, while  in  an  advanced  normal  pregnancy  with  a  living  child,  the  evi- 
dence for  an  extra-uterine  condition  lies  almost  always  in  the  distinctness  with 
which  the  parts  of  the  child  can  be  felt  through  the  abdominal  walls. 

Pregnancy  Mistaken  for  Extra-uterine  Pregnancy. — I  have  seen  a  great  many 
cases  of  this  sort.     I  had  one  myself  about  twenty-five  years  ago,  the  woman 


202         MElSrORKHAGIA    AND    METKOKKHAGIA,       EXTEA-UTEKIXE    PKEGISTANCY. 

who  had  had  several  children  became  pregnant,  and  experiencing  some  sharp 
pains  on  the  left  side  came  to  me  for  examination.  I  found  a  uterus  which 
seemed  to  me  to  be  not  much  above  the  normal  size,  and  a  well-defined  tnmor  to 
the  left.  At  the  operation,  the  tumor  was  discovered  to  be  a  large  cystic  ovary, 
while  the  uterus  was  duly  enlarged  to  correspond  to  the  third  month  of  preg- 
nancy. The  cyst  was  removed  and  she  recovered  and  had  a  child  in  due  time 
per  vias  naturales.  A  more  attentive  examination  under  anesthesia  would  have 
saved  the  error.  These  cysts  are  so  characteristically  globular  and  thin  walled 
and  can,  as  a  rule,  be  felt  so  readily  connected  with  the  ovary,  that  they  ought 
not  to  be  confused  with  any  other  condition. 

Again  a  mistake  of  this  kind  must  be  guarded  against.  In  the  early 
months  of  pregnancy  the  cervix  maintains  its  integrity,  while  the  uterine  body 
often  becomes  remarkably  softened  and  it  may  be  flaccid  so  that  it  seems  at  the 
first  touch  to  be  entirely  independent  of  the  cervix,  and  rather  like  some  boggy 
tumor  lying  near  by.  In  such  a  case  the  examiner  catches  the  cervix  and 
draws  it  down  until  he  feels  its  upper  end,  which,  if  it  is  a  long  cervix,  he 
may  readily  mistake  for  the  fundus  of  a  small  uterus,  the  natural  inference 
then  is  that  the  ill-defined  mass  beyond  is  an  extra-uterine  pregnancy.  Such 
a  mistake  will  not  occur  if  the  examination  is  made  under  an  anesthetic  and 
the  direct  organic  connection  between  the  cervix  and  the  mass  above  more 
carefully  studied. 

Again  a  pregnancy  may  be  mistaken  for  an  extra-uterine  pregnancy  when 
the  ovum  lodges  in  one  uterine  cornu,  and  this  softens  remarkably  as  the  preg- 
nancy advances,  while  the  opposed  half  of  the  uterine  body  remains  hard.  I 
have  seen  this  condition  repeatedly  during  the  past  twenty-five  years  and 
watched  it  gradually  disappear  as  the  pregnancy  advanced  into  the  fourth  or 
fifth  months.  Dr.  R.  L.  Dickinson  has  called  particular  attention  to  it  in  a 
paper  published. 

The  condition  is  a  most  puzzling  one  when  seen  for  the  first  time,  resembling 
either  an  extra-uterine  pregnancy  pure  and  simple  or  an  interstitial  ovum 
developing  in  that  portion  of  the  uterine  tube  which  traverses  the  uterine  cornu, 
or  again,  a  j^i'egnancy  in  one  horn  of  a  bicornuate  uterus.  An  examination 
per  rectum  may  only  serve  to  confirm  the  suspicion  that  the  pregnancy  is  ectopic. 
Added  to  the  surprising  anatomical  facts  is  the  additional  one  that  the  condi- 
tion is  often  associated  with  much  pain  in  the  sac.  If,  however,  the  examiner 
is  well  on  his  guard,  he  will  recognize  by  a  rectal  examination  under  anesthesia 
that  the  softish  mass  occupies  exactly  the  position  of  one  whole  side  or  of  the 
right  or  left  upjDcr  corner  of  the  uterus,  and  at  the  same  time  he  will  notice  the 
extraordinarily  broad  connection  with  the  remaining  portion  of  the  uterus 
and  will  correct  the  erroneous  notion  formed  at  a  previous  examination,  that 
the  mass  is  in  any  sense  really  distinct  from  the  uterus. 

I  must  confess  I  don't  know  just  how  to  distinguish  this  condition  from  an 
interstitial  pregnancy,  except  that  interstitial  cases  seem  to  be  so  rare,  and 
on  the  other  hand  these  cornual  cases  seem  to  shade  off  into  those  in  which 


EXTRA-TJTEKINE    PKEGNANCY    AND    NORMAL    PREGNANCY.  203 

the  whole  of  one  side  is  softened.  It  is  yet  possible  that  many  of  this  group 
are  in  reality  interstitial  and  subsequently  become  intra-uterine,  in  accord  with 
a  number  of  clinical  observations  made  about  two  decades  ago. 

One  of  my  patients  some  years  ago  had  so  much  pain  with  her  condition 
that  although  I  was  tolerably  sure  of  my  diagnosis,  I  opened  the  abdomen  to 
verify  it,  when  I  found  a  bluish  thin-walled  cystic  mass  about  6  cm,  in  diameter 
at  the  right  uterine  cornu  sessile  on  the  firm  uterine  body.  The  fetus  after- 
wards escaped  per  vaginam. 

Cases  of  advanced  pregnancy  mistaken  for  extra-uterine  pregnancy  are 
almost  always  those  with  phenomenally  thin  abdominal  walls.  The  sharply 
defined  limbs  of  the  fetus  seem  to  lie  in  direct  contact  with  the  wall  without 
any  intervening  tissue. 

A  case  of  this  kind  occurred  in  the  wife  of  a  physician  from  Iowa,  unusual 
in  that  the  one-sided  hardening  and  want  of  development  of  the  uterus  per- 
sisted well  into  the  fifth  month.  I  examined  most  carefully  and  counseled 
delay,  my  visitor  waited  for  some  time  not  without  trepidation,  then  he  took 
his  wife  home  and  later  wrote  me  of  her  timely  and  natural  delivery. 

The  general  practitioner  often  finds  it  hard  not  to  jump  at  once  to  the 
conclusion  that  he  is  dealing  with  a  mature  extra-uterine  ovum.  The  specialist 
to  whom  he  brings  the  case  at  once  makes  a  careful  vaginal  or  rectal  examina- 
tion, under  anesthesia  if  needs  be,  in  order  to  answer  the  deciding  question, 
"  Where  is  the  uterine  body  ?  "  If  the  fetus  is  extra-uterine,  it  will  be  a  simple 
task  to  find  and  outline  a  normal  uterine  body  and  so  confirm  the  diagnosis. 
With  rare,  very  rare  exceptions  the  pregnancy  is  normal  and  goes  on  to  term 
and  a  normal  delivery.  In  several  instances  patients  have  come  to  me  because 
the  consultants  at  home  had  urged  an  operation  then  and  there  to  save  the 
mother's  life  from  imminent  peril.  I  incurred,  I  fear,  the  lasting  displeasure 
of  two  physicians  in  the  Southwest  who  were  more  than  usually  positive  and 
insistent,  by  venturing  to  say  the  child  was  in  the  uterus  and  the  pregnancy 
might  proceed  unmolested.  The  event  verified  the  prediction,  though  it  took 
place  in  rival  hands. 

There  was  a  case  of  advanced  pregnancy  in  the  practice  of  the  late  A.  K. 
Minich,  of  Philadelphia,  which  he  took  for  extra-uterine  from  a  vaginal  exami- 
nation, for  while  he  felt  the  cervix  high  up  and  the  large  fetal  head  could  be 
distinguished  with  the  utmost  plainness  in  the  cul-de-sac  low  down,  a  most 
careful  examination  showed  that  this  was  one  of  those  rare  cases  of  retroflexion 
of  the  pregnant  uterus  persisting  almost  to  the  end  of  pregnancy,  that  is  to  say, 
while  the  uterine  body  developed  above,  a  diverticulum  remained  below  in  which 
the  head  was  lodged.  At  the  end  of  the  pregnancy  this  disappeared  entirely, 
and  I  attended  her  later  in  a  normal  labor. 

I  saw  a  case  but  recently  with  one  of  my  colleagues.  A  woman  who  had 
never  been  pregnant  ceased  menstruating  early  in  July.  On  September  30th, 
while  sitting  in  a  chair,  she  was  suddenly  taken  with  severe  pain  in  the  lower 
abdomen.     Since  that  time  she  had  been  obliged  for  some  ten  days  to  stay 


204         ME^^OEKHAGIA    A^^I>    :\IETEOBKHAGIA.       EXTKA-UTEEIK^E    PEEGNAI^'CT. 

I^rettT  constantly  in  bed^  \vitli  severe  pains.  There  was  extreme  tenderness 
over  the  abdomen,  some  pallor  associated  with  localized  congestions,  tympany, 
and  slight  fever,  varying  from  99°  to  100.8°  F.  The  bowels  were  constipated 
and  there  was  bearing  down.  When  I  examined  her  I  found  a  more  or  less 
diffuse  distention  of  the  lower  abdomen,  and  felt  the  coils  of  intestine,  appar- 
ently adherent,  running  over  the  mass.  Vaginal  examination  showed  extreme 
tenderness  and  the  uterus  appeared  lost  in  the  mass.  There  was  no  vaginal 
flow.  The  vagina  was  discolored-  dark.  The  uterus  could  not  be  felt  biman- 
ually  on  account  of  the  general  tenderness,  but  there  was  a  fulness  and  resilience 
at  the  vaginal  vault  on  all  sides.  The  extra-uterine  pregnancy  seemed  so  clear 
that  I  sent  her  to  the  hospital.  On  returning  I  made  an  incision  without  further 
examination,  and  the  pregnancy  proved  to  be  intra-uterine  and  normal,  while 
the  pains  were  undoubtedly  caused  by  strong  omental  adhesions  to  the  abdom- 
inal wall.  The  adhesion  was  severed  and  the  patient  has  since  done  well.  The 
error  in  the  diagnosis  would  not  have  occurred  if  I  had  examined  the  patient 
under  anesthesia  just  before  the  operation,  and  this  ought  always  to  be  done. 

The  error  of  considering  an  extra-uterine  pregnancy  as  a  normal  pregnancy  in 
utero  is  a  far  commoner  one  than  the  opposite  mistake  upon  which  I  have  just 
dwelt.  Almost  all  extra-uterine  pregnancies  are  so  mistaken  in  the  early  months, 
and  this  is  the  cause  of  many  of  the  tragedies  which  occur  with  such  a  dramatic 
ending.  A  patient  who  becomes  pregnant  whether  intra-uterine  or  extra-uterine 
ceases  to  menstruate,  and  step  by  step  acquires  certain  of  the  signs  of  pregnancy, 
such  as  nausea,  fulness  of  the  breasts,  discolorization  of  the  vagina,  some  en- 
largement of  the  uterus,  the  formation  of  a  tumor  which  can  be  felt  above  the 
symphysis.  Until  there  is  some  unusual  sensation  or  discomfort  or  accident, 
such  as  pain  and  hemorrhage,  the  patient  has  no  reason  to  think  that  there  is 
anything  wrong  with  her.  When,  however,  things  begin  to  go  wrong  and  the 
termination  of  the  pregnancy  seems  threatened  or  she  falls  over  in  a  faint,  a 
doctor  is  called  for  and  the  local  examination  reveals  a  uterus  which  is  empty, 
and  a  mass  situated  at  one  side  of  the  uterus.  Associating  this  with  the  dis- 
charge and  the  history  of  pain,  the  physician  promptly  makes  a  diagnosis  of 
extra-uterine  pregnancy  and  operates.  All  these  familiar  signs  are  so  well 
known  to  the  average  practitioners  of  to-day,  that  they  only  have  to  be  repeated 
to  the  successive  generations  of  graduating  students  to  perpetuate  the  clear 
teachings  of  our  immediate  predecessors  who  cleared  up  this  difficult  field.  One 
sometimes,  however,  meets  with  cases  which  have  been  strangely  neglected  in 
spite  of  the  plainest  evidences  of  an  extra-uterine  pregnancy.  It  is  important 
for  this  reason,  in  order  to  rescue  more  lives  from  such  a  sudden  and  dreadful 
death,  to  iterate  and  reiterate  the  important  signs  by  which  extra-uterine  preg- 
nancy is  to  be  distinguished  from  normal. 

Fibroid  Tumors  Mistaken  for  Pregnancy. — Fibroid  tumors  are  perhaps  the 
commonest  of  all  major  g^mecological  ailments,  and  it  is  not  surprising  that 
occasionally  a  group  of  tumors  may  be  found  which  closely  resemble  the  form 
of  the  fetus.     At  least  two  such  cases  have  come  under  my  notice,  and  another 


EXTEA-UTERINE    PREGNANCY    AND    NORMAL    PREGNANCY.  205 

lias  occurred  in  the  practice  of  Dr.  E.  E.  Montgomery.  Tlie  figure  in  tlie  text 
shows  the  characteristic  appearance  and  the  ease  with  which  the  tumors  might 
readily  be  mistaken  for  the  prominent  parts  of  the  child.  Again,  given  an 
abdomen  moderately  distended  with  ascites,  such  as  is  occasionally  seen  in  con- 


FiG.  70A. — A  Myomatous  Uterus  Resembling  a  Fetus  in  Its  Contour.  The  enlarged  uterus 
measured  II  X  13  X  21  cm.  The  nodule  just  behind  the  left  ovary  might  readily  have  been  mis- 
taken for  the  head  on  palpation,  and  the  large  one  behind  the  right  ovary  for  the  buttocks. 
The  appendages  were  normal.     The  right  tube  apparently  emerges  from  a  small  myoma. 

nection  with  fibroids,  and  in  this  a  pedunculate  fibroid  tumor,  one  may  easily 
recognize  the  sign  of  ballottement  pushing  the  tumor  back  in  the  fluid,  when 
its  pedunculate  or  hinged  attachment  causes  it  to  return  against  the  examining 
finger.  In  this  way  one  of  the  most  characteristic  signs  of  pregnancy  is  mim- 
icked. In  both  these  classes  of  cases  other  signs  of  pregnancy  are  absent,  and 
an  attentive  examination  will  show  that  there  is  no  real  ground  for  supposing 
its  presence,  though  in  one  case  a  patient  had  gone  so  far  as  to  make  a  wardrobe 
for  the  expected  infant. 

The  diagnosis  may  be  made  between  extra-uterine  pregnancy  and 
abortion,  by  noting  the  passage  of  an  ovum  in  the  latter,  and 
the  absence  of  the  lateral  tumor,  as  well  as  the  less  intense, 
agonizing  character  of  the  pains.  If  there  still  remains  a  doubt,  it 
is  best  to  examine  under  anesthesia  and  to  curette  the  uterus.  The  danger  is 
far  greater  of  mistaking  an  extra-uterine  pregnancy  for  an  abortion,  than  of 
mistaking  an  abortion  for  an  extra-uterine  pregnancy.  When  the  patient  is 
stout  and  the  tumor  is  a  small  one,  situated  in  the  isthmus ;  or  when  there  is  a 
flaccid  ovum  in  the  ampulla  and  the  fluid  blood  is  distributed  through  the  in- 
testines, the  greatest  expert  may  not  be  able  to  decide  immediately  just  what 
the  trouble  is.  In  cases  of  serious  continued  doubt,  it  is  best  to  make  a  vaginal 
or  abdominal  incision  and  set  the  uncertainty  at  rest. 

A  salpingitis  may  be  accompanied  by  marked  fever  and  is 
often  bilateral.  But  even  here  a  pyosalpinx  may  upset  the  diagnosis 
of  the  most  expert  practitioner.  The  symptom  commonly  lacking  is  the  uterine 
hemorrhage ;  if  there  is  time  to  wait  and  curette,  there  is  of  course  no  decidua. 
A  Graafian  follicle  cyst  or  a  small  ovarian  tumor  may  also  be 
the   source   of   an  error. 


206         MENORRHAGIA    AISTE    METRORRHAGIA.       EXTRA-IJTERIN"E    PREGNAKCT. 

In  appendicitis,  we  have  the  pain,  and  the  muss  extending 
np  into  the  right  iliac  fossa  ;  also  the  fever  and  the  increased 
lencocyte  conut;  but  with  these  signs  there  is  the  absence  of 
anything  pointing  towards  pregnancy  nor  is  there  a  tnmor  to 
the  side  of  the  womb.  It  is  an  old  diag-nostic  measure,  and  one  of  value, 
to  use  a  small  aspirating  needle  to  puncture  the  vaginal  vault  and  withdraw 
some  of  the  dark  fluid  blood.  He  who  has  done  this  in  the  presence  of  a  tumor 
and  the  pains  in  a  case  of  presumptive  pregnancy  can  afford  to  be  very  wise 
and  very  positive  as  to  his  diagnosis !  ISTeed  I  caution  the  physician  to  treat 
the  little  expedient  with  the  same  care  as  to  asepsis  as  he  would  a  major 
operation  ? 

Treatment. — If  the  patient  has  been  suddenly  smitten  down  with  severe  ab- 
dominal pain  and  hemorrhage,  if  there  is  evidently  some  kind  of  a  mass  in  the 
pelvis  while  she  is  markedly  anemic,  it  is  best  to  consider  the  diagnosis  while 
getting  the  instruments  out  of  the  kit  to  open  the  abdomen  and  stop  the  hemor- 
rhage. There  should  be  no  academic  discussions  under  such 
circumstances,  for  such  cases  brook  no  delay,  and  he  who  acts  or  secures 
action  most  quickly  will  save  the  most  lives.  It  is  self-evident  that  in  the  pres- 
ence of  bleeding  which  will  eventually  destroy  life,  every  minute  is  precious. 

While  summoning  surgical  aid  in  cases  of  hemorrhage,  the  physician  should 
enjoin  absolute  rest,  flat  on  the  bed,  with  the  legs  and  arms  evenly  bandaged 
from  the  toes  and  fingers  up  to  the  trunk  to  keep  the  blood  in  the  body.  The 
foot  of  the  bed  should  be  elevated  from  ten  to  eighteen  inches,  to  keep  the  blood 
more  in  the  heart  and  head.  It  is  best  not  to  give  cardiac  stimulants;  dig- 
italis  especially   ought   never   to   be   used. 

Most  important  of  all  remedies,  as  a  rule,  is  the  infusion  under  the  breasts, 
of  one  thousand  cubic  centimetres  of  a  normal  saline  solution  six-tenths 
per  cent;  that  is  to  say  one  made  up  with  a  small  teaspoonful  of  table  salt  to 
the  pint  of  warm  water  passed  slowly  in  by  gravity  through  a  large  cannulated 
needle  from  a  fountain  syringe.  It  is  well  to  consume  about  half  an  hour  in 
this  operation  (see  p.  184).  To  the  saline  solution  may  be  added  twenty  to 
thirty  minims  of  a  solution    of    adrenalin    (1:1000). 

While  waiting  for  surgical  aid,  much  may  be  done  to  save  time  by  getting 
the  room  ready,  and  by  preparing  plenty  of  hot  water,  towels,  and  clean  vessels. 
It  is  often  best  to  give  the  preliminary  cleansing  of  the  abdomen  in  bed  before 
administering  the  anesthetic.  The  physician  must  see  to  it  that  the  patient 
remains  as  short  a  time  as  possible  under  the  anesthesia,  and  the  surgeon  must 
be  ready  to  begin  the  operation  as  she  is  lifted  onto  the  table. 


CHAPTER    VIII. 

CONSTIPATION.     HEADACHE.     INSOMNIA.     OBESITY. 

(1)  Constipation:    Definition,  p.  207.     Effects,  p.  207.     Act  of  defecation,  p.  208.     Etiology, 

p.  212.     Frequency,  p.  213.     Diagnosis,  p.  214.     Treatment,  p.  216. 

(2)  Headache:  Frequency,  p.  224.     Etiology,  p.  224.     Diagnosis,  p.  229.     Treatment,  p.  229. 

(3)  Insomnia:  Frequency,  p.  238.  Etiology,  p.  238.     Treatment,  p.  239. 

(4)  Obesity:  Definition,  p.  244.    Etiology,  p.  244.    Treatment,  p.  245.   Adiposis  dolorosa,  p.  248. 

CONSTIPATION. 

Definition.  —  Constipation  is  the  infrequent  action  of  the  bowels,  in  conse- 
quence of  which  the  waste  products  of  the  intestinal  tract  are  retained  for 
periods  of  one  or  more  days  beyond  the  normal.  Habitual  constipation  may 
also  be  defined  as  a  sluggish  habit  of  the  body,  in  which  the  bowels  fail  to 
respond  to  the  presence  of  the  fecal  matter,  which  should  excite  a  desire  for 
evacuation  as  it  is  propelled  into  the  rectum.  It  is  one  of  the  commonest  ab- 
normal conditions  with  which  the  physician  has  to  deal,  and  is  the  cause  of 
much  ill-health  and  discomfort  in  women. 

Effects. —  In  constipation,  nutrition  and  metabolism  are  interfered  with  and 
serious  circulatory  disturbances  arise  from  the  choking  of  the  in- 
testinal tract;  from  the  copremia  (constipation  anemia)  caused  by  absorp- 
tion of  the  poisonous  retained  products;  and  from  the  local  stasis  in  the 
hemorrhoidal  vessels,  which  may  be  continued  up  into  the  portal  system 
and  into  the  liver. 

Patients  habitually  constipated  are  apt  to  show  it  in  their  faces:  a  muddy 
complexion  in  young  girls,  often  associated  with  facial  acne,  is  characteristic 
of  constipation.  Constipation  is  also  apt  to  be  manifested  in  the  temper,  which 
is  melancholic,  and  also  in  the  listlessness,  which  takes  the  place  of  energy. 

The  mechanical  circulatory  disturbances  and  the  poisonous  products  reab- 
sorbed from  the  lower  intestinal  tract  have  often  a  pronounced  effect 
upon  the  digestion,  inducing,  apparently,  a  sluggishness  in  the  upper 
intestinal  tract,  with  gas,  belching,  and  loss  of  appetite. 

In  a  word,  so  long  as  a  pronounced  constipation  is  the  habit  of  the  body, 
all  the  organs  are  bathed  daily  in  blood  rendered  impure  by  the  absorption  of 
fecal  products,  and  the  consequences  are  usually  those  which  might  be  legiti- 
mately expected. 

It  would  be  interesting  and  important  to  determine  how  far  a  habit  of 

constipation  may  be  responsible  for  the  slow  evolution  of  far  graver  diseases 

of  the  organs  of  the  body  cavity  and  of  the  brain. 

207 


208  COIirSTIPATION.        HEADACHE.        INSOMNIA.       OBESITY. 

The  local  expression  of  constipation  in  women  is  often  pronounced.  In  the 
first  place  •  the  retention  of  feces  in  the  rectum,  especially  in  that  part  which, 
lies  back  of  the  uterus,  above  "  the  third  sphincter,"  frequently  gives  rise  to 
colicky  pains  in  the  pelvis  which  are  easily  mistaken,  as  are  the  tender 
masses  themselves  when  felt  through  the  vagina,  for  diseased  ovaries.  I  once 
opened  an  abdomen  thinking  I  had  an  acute  recrudescence  of  a  pelvic  peri- 
tonitis, to  find  nothing  but  a  mass  of  unchewed,  undigested  beans  in  the  rectum 
in  this  situation. 

The  pelvic  stasis  produced  by  the  constipation  is  not  only  the  cause  of 
the  hemorrhoids  readily  seen  at  the  anal  orifice,  but  of  a  similar  dilata- 
tion of  the  venous  channels  in  direct  communication  with  them  above. 
This  pelvic  congestion  makes  itself  felt  in  a  sense  of  weight  and  bearing  dovni, 
referred  to  the  pelvis  at  large,  and  it  may  also  be  responsible  for  the  large 
varices  seen  in  the  broad  ligaments  on  opening  the  abdomen.  To  this  local 
stasis  some  authors  of  repute  refer  certain  cases  of  endometritis.  A 
marked  and  a  misleading  sensitiveness  is  apt  to  characterize  the 
organs  involved  in  it.     Backache  of  the  sacral  form  is  a  common  feature. 

]^ot  a  few  cases  of  dysmenorrhea  in  young  girls  are  due  to  habitual 
constipation  and  are  relieved  when  a  daily  action  of  the  bowels  is  established. 
Constipation  is  commonly  associated  with  many  pelvic  ailments,  and  is 
often  a  source  of  trouble  after  abdominal  operations. 

To  realize  the  whole  bearing  of  constipation  upon  the  health  of  the  indi- 
vidual, it  is  necessary  to  have  some  definite  knowledge  of  nature's  scheme  for 
the  evacuation  of  the  bowels  as  the  completion  of  the  whole  process  of  digestion. 

The  process  of  digestion  attains  completion  in  the  large  intestine,  and  by 
the  time  the  food  reaches  the  rectum  all  the  nutritious  material  which  can  be 
assimilated  has  been  absorbed,  almost  all  the  liquids  have  been  taken  back  into 
the  system,  and  nothing  remains  but  an  indigestible  residuum,  connnonly  known 
as  feces.  When  the  normal  quantity  of  food  taken  into  the  body  cavity  daily 
is  estimated,  it  is  evident  that  the  residue  remaining  after  digestion  and  ab- 
sorption of  the  three  meals  should  also  be  daily  removed,  if  the  digestive  tract 
is  to  be  kept  open  and  its  functions  properly  maintained.  In  a  normal  condi- 
tion, the  rectum  ought  to  be  evacuated  once  in  twenty-four  hours,  and  the  whole 
structure  of  the  intestinal  tract  is  arranged  to  further  this  end.  The  peristaltic 
action  of  the  muscular  coats  of  the  large  and  small  intestines  is  constantly  at 
work  to  drive  the  food  onward,  while  the  valves  occurring  at  frequent  intervals 
throughout  the  intestines  are  so  arranged  as  to  facilitate  its  downward  move- 
ment. The  propulsion  of  the  column  of  ingestion  from  the  last  meal  also  serves 
as  a  powerful  stimulus  to  the  intestinal  tract  beyond  to  empty  itself  into  the 
next  succeeding  portion  until  the  end  of  the  tract  is  reached,  where  it  should 
normally  produce  a  desire  for  an  evacuation. 

Defecation. — Expulsion  of  the  residual  mass,  which  is  known  as  the  act  of 
defecation,  is  accomplished  through  the  relaxation  of  the  sphincter  ani  mus- 
cles, aided  by  the  peristaltic  action  of  the  intestinal  tract  above,  associated  with 


ACT    OF    DEFECATION. 


209 


the  voluntary  action  of  the  abdominal  muscles.  We  are  accustomed  to  think 
of  such  an  action  as  voluntary,  because  the  part  taken  in  it  by  the  abdominal 
muscles  is  impressed  upon  the  consciousness,  but  it  really  originates  in  and 
arises  fundamentally  from  the  peristaltic  action  of  the  muscular  coat  of  the 
intestines,  which  is  independent  of  volition,  as  shown  by  defecation  taking  place 
under  certain  conditions  without  the  knowledge  of  the  individual ;  for  example, 
it  constantly  occurs  in  this  manner  after  the  section  of  the  spinal  cord.  The 
anatomical  arrangements  are  such  that  the  act  of  defecation,  as  planned  by 
nature,  should  progress  as  a  steady,  gentle  evacuation  of  the  lower  intestinal 
contents,  without  any  risk  of  eversion  or  prolapse  of  the  mucosa. 

The  regular  evacuation  of  the  bowels  is  largely  influenced  by  the  character 
and  amount  of  the  food  taken  into  the  body.  If  little  food  is  eaten,  there  will, 
of  course,  be  little  residue,  and  if  the  food  is  too  readily  assimilated,  it  will 
almost  all  be  absorbed,  and  there  will  be  little  or  nothing  to  pass  down  into  the 
rectum.  It  follows,  therefore,  that  a  mixed  diet,  composed  of  a  variety  of  easily 
assimilated  foods,  as  well  as  other  kinds  which  contain  sufficient  fibrous,  inert, 
and  indigestible  matters  to  form  a  residue,  is  that  best  adapted  to  the  regulation 
of  the  bowels,  as  well  as  to  the  other  needs  of  the  body. 

People  who  change  their  diet  materially,  or  take,  for  a  time,  less  amounts 
than  they  are  accustomed  to,  as  in  travelling,  visiting,  or  taking  a  sea  voyage, 
are  apt  to  sufi^er  from  irregular  action  of  the  bowels,  until  they  have  adjusted 
themselves  to  the  new  conditions. 

In  normal  defecation  four  factors  are  present,  namely: 

(1)  The  lower  bowel  and  the  rectum  must  have  something  to 
handle  ;  that  is  to  say,  a  mass  of  excrementitious  matter  extending  like  a 
broken  or  faceted  column  upward  towards  the  pelvic  brim. 

(2)  The  material  present  must  excite  an  impulse  to  evacuation, 
that  is  to  say,  the  physiological  sensibility  of  the  rectum  must  be  normal. 

(3)  The  mechanism  of  the  muscular  apparatus  of  the  lower 
bowel,  and  the  voluntary  muscles  of  the  abdominal  walls  must  be 
such  that  they  shall  be  duly  able  to  expel  the  accumulated  ex- 
crement. 

(4)  While  the  lower  part  of  the  column  of  excrement  is  in  the 
act  of  passing  the  sphincter  area  the  upper  part  of  the  rectum 
must  in  turn  send  down  its  contents  to  be  expelled  in  due  order. 

All  these  conditions  are  fulfilled  in  every  normal  act  of  defecation,  which, 
if  examined  attentively,  will  be  seen  to  resemble  a  miniature  act  of  parturi- 
tion. In  the  first  place,  there  are  slight  premonitory  feelings  of  uneasiness, 
becoming  more  and  more  decided  and  insistent,  and  finally  ending  in  a  well- 
defined  "  bearing-down  pain."  At  the  suitable  moment  the  levator  ani  relaxes 
and  lets  down  the  pelvic  floor,  upon  which  the  fecal  mass  enters  the  internal 
sphincter  area,  which  in  its  turn  also  relaxes.  Then,  with  the  contraction  of 
the  abdominal  muscles  and  the  forward  inclination  and  approximation  of  the 
thighs  to  the  abdomen,  the  external  sphincter  area  yields,  the  bolus  passes 
15 


210 


COiXSTIPATIOX. 


HEADACHE.       II^SOMK^IA.        OBESITY. 


tliroiigli  and  escapes,  and  the  miniature  delivery  is  accomplished,  formally 
defecation  should  represent  parturition  without  pain.  It  is  interesting  to  note 
that  the  internal  sphincter  muscle  is  in  some  measure  under  the  control  of  the 
will;  the  act  of  bearing  down  relaxes  it,  while  a  voluntary  act  of  drawing  up, 
that  is  to  say  of  lifting  the  levator  and  tightening  the  external  sphincter, 
tightens  the  internal  sphincter  simultaneously. 

The  best  and  most  efficient  method  of  defecation  and  that  which  best  econo- 
mizes expenditure  of  force,  when,  as  is  often  the  case,  there  is  a  difficulty  in 
expulsion,  is  found  in  attendance  upon  nature's  call  after  the  manner  of  all 
primitive  people  in  a  squatting  posture  in  the  bushes  sub  Jove  (see  Fig.  71). 
In  this  natural  and  instinctive  habit  lies  perhaps  the  strongest  link  in  the  chain 
which  binds  us  to-day  to  our  ancestral  life.  Everywhere,  the  yokel  who  retires 
behind  the  barn,  and  the  schoolboy  who  insists  upon  climbing  up  onto  the  seat, 
seek  to  perpetuate  it,  not  to  mention  the  number  of  highly  civilized  society  men 
who  day  by  day  leave  their  traces  behind  them,  as  they  wear  off  the  varnish 


Fig.  71. — Postttre  ix  Defecatiox,  sho-wixg  the  Efficiext  Use  of  Abdoaiixal  Pressure  tx  the 
Croitchixg  Positiox,  the  Axterior  Abdomixal  "Wall  beixg  Supported  by  the  Close  Applica- 
Tiox  of  Thighs  to  the  Abdomex. 


from  the  modern  inconvenient  seats  with  the  soles  of  their  shoes,  a  mute  but 
eloquent  testimony  to  their  necessity.  Naturam  ex-pelles  furcd  iamen  usque 
recurret. 

The  disadvantage  of  the  high  water-closet  seats  found  everywhere  lies  in  the 
fact  that  in  the  act  of  expulsion  there  is  no  support  to  the  anterior  abdominal 


ACT    OF    DEFECATIOIN'. 


211 


wall  and  force  is  lost  there  (see  Fig.  72),  as  anyone  can  feel  by  placing  the 
fingers  in  the  inguinal  rings  and  straining.  It  lies  also  in  the  fact  that  the 
direction  of  the  strain  is  faulty.     One  of  two  things  should  he  done  to  remedy 


Fig.   72. — Posture  in  Defecation.     The  ordinary  sitting  posture  with  body  slightly  inclined,  showing 
the  loss  of  force,  indicated  by  the  arrows  pointing  toward  the  lower  anterior  abdominal  wall. 

this  evil :  either  the  closet  seats  ought  to  he  set  low  in  the  floor,  or  a  little  bench 
ought  to  be  provided  which  will  bring  the  feet  up  to  a  point  about  eight  and  a 
half  inches  from  the  level  of  the  seat  (see  Fig.  73).  Either  of  these  measures 
will  necessitate  widening  the  opening  in  the  seat  for  about  two  inches  at  a  point 
two-thirds  of  the  way  back,  on  account  of  the  change  in  the  form  of  the  but- 
tocks and  the  greater  prominence  of  the  ischial  tuberosities. 

The  rectum  does  not  normally  harbor  feces.  As  soon  as  the 
fecal  mass  descends  from  the  sigmoid  and  is  felt  in  the  lower  rectum  it  should 
be  expelled.  If  the  impulse  is  resisted,  it  either  returns  to  the  upper  bowel  by 
a  reverse  peristalsis,  or,  if  this  is  prevented  by  the  accumulation  above,  it  re- 


212 


CONSTIPATION.       HEADACHE.       INSOMNIA.       OBESITY. 


mains  in  the  rectum  and  blunts  the  normal  sensibility,  constipation  being  the 
outcome. 

Etiology. — ^Retention  of  feces,  constipation,  or  obstipation  may 
arise  from  a  variety  of  causes,  which  are : 

1.  Lack  of  a  right  habit  in  attending  to  the  function  of  the  bowel. 

2.  Lack  of  exercise. 

3.  Lack  of  proper  food. 

4.  Injury  to  the  mechanism  at  the  end  of  the  bowel,  due  to  parturition. 

5.  Redundant  sigmoid  with  a  long  meso-sigmoid. 

6.  Diseases  of  the  intestinal  tract,  or  of  the  pelvic  organs. 

It  will  be  seen  that  these  causes  must  operate  more  frequentlj-  in  women 
than  in  men.  Perhaps  the  most  important  is  habit,  or  rather  the  failure 
on  the  part  of  the  individual  to  establish,  or  to  maintain  a  regu- 
lar habit  of  body.  Many  women  pay  no  attention  whatever  to  the  regular 
action  of  the  bowels,  except  when  forced  to  do  so  by  their  excessive  and  increas- 
ing discomfort. 

The  reason  for  this  among  the  poor  may  well  lie  in  the  atrocious  ar- 
rangements for  the  care  of  the  bodily  functions  afforded  by 
our  civic  authorities,  whereby,  for  instance,  one  closet  is  made  to  serve 
for  several  families.  In  a  tenement  in  Baltimore,  two  closets  do  service 
for  twenty-two  families  (see  Fig.  35,  p.  48).  Associated  with  the  use 
of  such  "  conveniences  "  is  often  an  advertising  of  the  necessity 
which  borders  close  on  indecent  exposure.  Better  for  the  poor 
girl  to  restrain  her  natural  desires  and  force  the  function  into 
an  intermittency  of  expression,  which  is  marked  by  intervals  of 

days.  We  will  do  well  to 
seek  here  for  one  of  the  po- 
tent causes  of  the  immorality 
which  is  everywhere  on  the 
increase. 

With  the  better-to-do  wom- 
an, a  false  modesty  often 
restrains  her  from  attending 
to  this  function;  she  is  afraid 
of  meeting  some  one  on  the 
way.  Again  it  is  frequently 
put  off  as  a  mere  matter  of  in- 
convenience until  nature's  calls 
are  so  often  stifled  that  at  last  the  sense  gTows  blunt  and  the  constipation  habit 
is  established. 

Too  numerous  also  are  the  cases  in  which  a  grown  man  or  woman,  whose 
training  has  been  neglected  in  this  respect  in  childhood,  continues  to  suffer  at 
maturity :  the  responsibility  for  constipation  of  this  sort  must  rest  on  parental 
shoulders — a  word  to  the  wise  is  sufficient. 


Fig.  73. — ^An  Adaptation  of  the  Modern  Sanitary  Closet 
TO  Utilize  the  Crouching  Posture  by  Raising  the 
Feet  tvithin  Eight  and  a  Half  Inches  of  the  Level 
OF  THE  Seat  by  Means  of  a  Stool. 


ETIOLOGY    OF    CONSTIPATION.  213 

Lack  of  proper  exercise  and  sedentary  occupation  often  result 
in  constipation.  Persons  whose  occupations  afford  them  little  or  no  opportunity 
for  active  exercise  are  peculiarly  liable  to  it.  Weakness  of  the  abdom- 
inal muscles  interfering  with  the  passage  of  the  food  downward  is  often 
associated  with  a  lack  of  physical  exertion.  A  feeble  or  capricious  ap- 
petite, which  interferes  with  the  consumption  of  a  sufficient  quantity  of  food, 
is  another  result  of  insufficient  exercise. 

Parturition  often  seriously  interferes  with  the  mechanism  of  the  lower 
bowel  by  causing  a  rupture  of  the  levator  ani  fibres,  especially  those  interlock- 
ing with  the  internal  sphincter,  so  that  the  bowel  is  no  longer  lifted  up,  but 
drops  forward  in  the  direction  of  the  ruptured  perineal  muscles.  In  such  a 
case  as  this  the  efforts  at  expulsion  tend  to  produce  eversion  of  the  vaginal 
outlet  so  that  the  expulsive  power  is  lessened  or  rendered  nugatory. 

In  addition  to  the  causes  enumerated,  any  of  which  may  exist  while  the 
patient  is  in  perfect  health  (except  for  the  presence  and  the  effects  of  the  con- 
stipation itself),  there  are  sundry  diseased  conditions  in  which  retention 
of  feces  occurs.  The  passage  of  feces  may  be  mechanically  interfered  with  by 
the  pressure  of  morbid  growths,  either  benign  or  malignant,  situated 
in  different  parts  of  the  abdomen  or  pelvis,  as  well  as  by  stricture  arising 
from  any  cause  whatever.  Chronic  disease  of  the  intestinal  mucosa 
may  result  in  atony  of  the  whole  intestine,  indeed  Osier  reckons  that  the  most 
frequent  local  cause  of  constipation  is  atony  of  the  colon,  particularly 
of  the  muscles  of  the  sigmoid  flexure  by  which  the  feces  are  propelled  into  the 
rectum.      ("Practice  of  Medicine,"  1892,  p.  421.) 

A  redundant  sigmoid  with  its  long  meso-sigmoid  affords  a  convenient 
place  for  the  lodgment  of  fecal  masses ;  the  profession  is,  indeed,  just  beginning 
to  attribute  importance  to  this  congenital  anatomical  condition  as  a  cause  of 
an  obstinate  form  of  constipation.  ITotable  work  on  these  lines  has  been  done 
by  Clark  and  Pancoast  in  their  X-ray  studies  in  Philadelphia.  In  some  cases 
Clark  has  operated  wath  conspicuous  success. 

Some  proctologists  attribute  importance  to  a  thickened  inflamed  con- 
dition of  the  rectal  valves,  associated  with  a  marked  overlapping  of 
their  margins,  rendering  the  channel  more  tortuous. 

One  of  the  most  serious  hindrances  to  the  normal  activity  of  the  bowel  is  a 
tight    corset. 

Frequency. — In  order  to  ascertain  something  as  to  the  frequency  and  the 
extent  of  constipation  in  my  daily  consultation  practice,  I  have  analysed  five 
hundred  cases  from  my  gynecological  case-books,  taking  them  in  order.  The 
age  of  the  youngest  patient  was  twelve  and  a  half  and  that  of  the  oldest  sixty- 
nine. 

The  total  number  of  cases  of  constipation,  either  habitual  or  occasional,  was 
one  hundred  and  sixty-four  out  of  five  hundred,  or  about  thirty-three  per  cent. 
Of  these,  sixteen  are  noted  as  occasionally  constipated,  while  seventeen  suffered 
to  an  extreme  degree.     Only  fifty-seven  of  the  hundred  and  sixty-four  were 


214  COIS^STIPATION".       HEADACHE.       INSOMNIA.       OBESITY. 

accustomed  to  use  any  means  to  overcome  the  difficulty,  forty-four  of  this  num- 
ber taking  medicines  of  various  kinds,  and  thirteen  using  an  enema.  Another 
noticeable  fact  is  that  in  almost  all  of  the  cases  in  which  there  was  no  record 
of  any  means  employed  for  relief,  the  constipation  is  noted  as  excessive 
or  as  having  existed   for   a   number   of  years. 

The  number  of  these  cases  suffering  from  headache  may  be  taken  as  a 
rough  indication  of  the  extent  to  which  the  body  in  general  was  affected  by  the 
loaded  condition  of  the  bowels.  Of  the  hundred  and  sixty-four,  eighty  com- 
plained of  headache  in  varying  degrees  of  severity,  while  five  suffered  from 
dizziness  without  actual  pain,  making,  in  all,  rather  more  than  half  of  the 
entire  number.  In  some  of  the  cases  in  which  the  constipation  is  noted  as  most 
marked  there  was  no  headache  at  all,  while  others,  where  it  was  mild  or  occa- 
sional, suffered  intensely  with  it.  In  some  cases  of  habitual  constipation  at- 
tacks of  sick  headache  with  nausea  and  vomiting  were  noted  as  ac- 
companying the  menstrual  periods.  The  number  of  cases  in  which  there  was 
any  indication  of  irritation  of  the  intestinal  mucosa  was  small,  as 
there  were  only  five  cases  where  there  was  mucus  in  the  stools,  and  but 
two  where  there  was   blood. 

Diagnosis. — In  making  a  diagnosis  of  constipation  as  the  cause  of  symptoms 
complained  of,  the  first  point  to  be  established  is  that  it  exists, 
and  this  is  a  matter  of  less  simplicity  than  it  seems.  So  many  women,  as  I 
have  said  above,  pay  little  or  no  attention  to  the  condition  of  the  bowels  that 
the  physician  is  constantly  liable  to  be  assured  that  they  act  with  perfect  regu- 
larity, when  they  are  really  emptied  only  every  three  or  four  days.  It  is  neces- 
sary that  he  should  be  explicit  in  his  inquiries  and  that  he  should  make  sure 
the  patient  understands  that  nothing  but  a  daily  motion  is  considered  normal. 

When  it  is  established  that  a  constipation  is  present,  we  must  next  consider 
its  form  and  its  causes,  ascertaining  the  following  facts : 

1.  What  is  the  state  of  the  general  health  ? 

2.  What  amount  of  exercise  is  taken  ? 

3.  Is  sufficient  food  ingested  to  form  a  fecal  mass  demanding  expulsion? 

4.  Where  does  this  mass  lodge  ?  Is  it  in  the  sigmoid  flexure  and  descend- 
ing colon  ? 

5.  Is  there  an  accumulation  in  the  caput  coli  ? 

6.  Is  there  an  accumulation  in  the  rectum  ? 

It  is  sometimes  convenient  to  classify  the  constipation  according  to  the  dif- 
ferent parts  of  the  large  intestine  in  which  the  fecal  matter  tends  primarily 
to  lodge:  as  rectal,  and,  if  rectal  whether  ampullar  or  upper  rectal, 
that  is,  above  the  utero-sacral  ligaments;  or  sigmoid  ;  or  colic.  Obstruct- 
ive forms  of  constipation,  when  the  obstruction  is  low  down,  say  in  a 
concentric  narrowing  of  the  rectum  due  to  cancer,  often  develop  slowly  and 
.  insidiously. 

In  order  to  ascertain  to  wliich  of  the  above  classes  the  constipation  belongs 
the  patient  must  go  without  a  purgative  for  two,  three,  or  more  days;  during 


DIAGlSrOSIS    OF    CONSTIPATION.  215 

"which  time  careful  daily  examinations  must  be  made  in  order  to  determine 
where  the  feces  lodge.  In  a  woman,  palpation  will  reveal  the  presence  of  any 
considerable  accumulation  in  the  region  of  the  cecum,  which  when  clogged  has 
a  doughy  pasty  feel,  is  movable  and  often  sensitive.  Only  in  extreme  cases 
can  masses  be  felt  above  the  cecal  region  in  the  transverse  and  the  descend- 
ing colon,  j^ot  infrequently,  however,  they  can  be  perceived  in  the  sigmoid 
flexure,  which  is  perceptible  to  the  touch  in  the  iliac  fossa,  or  behind  the 
symphysis,  or  near  the  promontory.  A  rectal  and  vaginal  examination  will 
reveal  the  presence  of  feces  in  the  lowest  portion  of  the  bowels.  In  these  cases 
I  constantly  use  the  protoscope,  introducing  it  as  far  as  the  sacral  promontory. 
The  patient  is  put  in  the  knee-breast  position  and  by  using  a  long  speculum, 
eighteen  centimetres  long  and  twenty  to  twenty-two  millimetres  in  diameter, 
I  can  examine  the  whole  lower  bowel.  In  young  women  it  will  often  prove 
that  the  lower  bowel  is  empty  and  that  the  difficulty  lies  in  the  fact  that 
the  fecal  mass  does  not  descend  into  the  rectum.  Such  an  investigation  is 
invaluable  in  suggesting  approximate  methods  of  treatment,  of  which  I  shall 
speak  later. 

Another  form  of  constipation,  which  can  be  detected  by  this  method  of 
examination,  is  that  in  which  the  overloaded  bowel  is  only  relieved 
of  a  portion  of  its  contents  at  each  act  of  defecation.  It  is  often 
a  good  plan  to  examine  women  who  are  much  troubled  with  constipation  within 
an  hour  or  two  after  what  they  consider  to  be  a  satisfactory  evacuation. 

In  women  who  have  borne  children,  the  vaginal  outlet  should  always  be 
examined  in  order  to  ascertain  whether  there  is  a  rupture  of  the  muscular  fibres 
and  a  consequent  tendency  to  eversion.  This  eversion  can  be  produced  arti- 
ficially by  inserting  one  or  two  fingers  into  the  rectum  and  pushing  the  mucosa 
forward  in  the  direction  of  the  vaginal  outlet  until  a  marked  pouch  is  formed 
by  the  protruding  vaginal  mucosa. 

It  must  next  be  ascertained  how  long  the  constipation  has  existed  and,  if 
possible,  what  occasioned  it.  If  it  is  habitual  and  has  lasted  a  number  of  years 
without  any  known  definite  starting  point,  it  is  probably  the  result  of  careless 
habit ;  but  if  it  has  developed  recently,  after  years  of  regularity,  the  possibility 
of  some  local  cause  must  be  considered,  such  as  pressure  from  a  pelvic 
tumor,  a  malignant  growth  in  the  intestine  itself,  or  a  stricture. 
The  diagTLOsis  of  these  affections  belongs  to  the  surgeon,  but  the  general  prac- 
titioner should  be  able  to  decide  upon  their  probable  existence. 

To  review  then,  in  any  given  case  it  must  be  determined:  that  constipa- 
tion exists  ;  that  it  is  of  mild  or  severe  type  ;  that  it  is  associated 
with  such  and  such  local  or  general  disturbances  ;  that  the  pa- 
tient is  or  is  not  free  from  organic  disease.  A  careful  palpa- 
tion of  the  abdomen  must  be  made  to  detect  the  lodgment  of  fecal  matter 
at  the  head  of  the  colon  or  in  the  transverse  and  descending  colon,  especially  at 
the  flexure;  an  endeavor  must  be  made  to  map  out  the  sigmoid  flexure  ; 
and    lastly,    a    local    pelvic    examination    must    be    made    to    determine 


216  COITSTIPATION.        HEADACHE.       INSOMNIA.       OBESITY. 

whether  there  is  or  is  not  an    obstruction    which  may  account  for  the  con- 
stipation on  purely  mechanical  grounds. 

It  is  a  good  plan  to  fill  out  some  such  scheme  as  this  in  the  case-book: 

Constipation  note : 

JSTanie.  Age.  Weight. 

1.  How  long  has  constipation  persisted  ? 

2.  Did  it  follow  any  acute  disease  or  change  in  habits? 

3.  Does  it  date  from  a  confinement? 

4.  What  are  the  longest  intervals  between  evacuations  ? 

5.  What  remedies  has  the  patient  been  accustomed  to  use  ? 

Treatment. — The  treatment  of  constipation  is  three-fold:  (1)  preventive; 
(2)  to  relieve  the  present  condition  by  unloading  the  bowel;  (3)  to  regulate 
the  function  so  that  it  will  act  automatically  and  without  artificial  aids. 

(1)  Prevention.^ — The  first  point  in  the  treatment  of  habitual  constipa- 
tion is  the  establishment  of  a  regular  daily  habit.  This  applies 
especially  in  the  training  of  young  girls,  with  all  of  whom  a  daily  effort  at  a 
fixed  time  is  sufficient  to  create  a  habit  which  becomes  at  last  a  second  nature. 
The  morning  call,  to  one  thus  trained,  becomes  an  imperative  demand  which 
is  never  neglected.  In  those  who  have  not  too  long  neglected  this  salutary 
habit,  the  mere  attitude  of  expectation,  created  by  a  persistent  morning  visit 
to  the  closet,  is  enough  after  a  while  to  regulate  the  function.  A  case  in  point 
which  shows  the  influence  of  the  mind  over  the  body,  is  one  where  the  patient 
suffered  extremely  from  constipation  until  she  became  a  "  Christian  scientist," 
after  which  she  made  an  effort  to  empty  the  bowels  every  day,  sitting  with  Mrs. 
Eddy's  manual  of  Christian  Science  in  her  hand,  with  perfect  success ! 

The  treatment  of  constipation  by  mental  influences  is  strongly  advocated 
by  Paul  Dubois  ("  The  Psychic  Treatment  of  ISTervous  Disorders  ")  as  follows: 

"  I  would  dare  to  say  that  the  cure  of  constipation  is  certain  if  one  uses 
these  means,  but  if  this  treatment  is  to  be  efficacious  it  must  be  prescribed  with 
entire  conviction.  This  I  insist  upon,  and  to  those  who  want  to  make  the 
attempt  I  will  give  the  following  advice:  (1)  Draw  the  patient's  attention  to 
the  inconvenience  of  laxatives  and  enemas ;  prohibit  them  altogether ;  burn  your 
bridges  without  fear.  (2)  State  that  one  always  succeeds  by  this  intelligent 
treatment.  If  you  have  already  had  some  success  along  such  lines  in  your 
practice,  describe  them  with  convincing  eloquence.  (3)  Ask  your  patient  when 
he  gets  up  and  takes  his  breakfast.  Ton  can,  to  a  certain  degree,  take  his 
habits  into  account.  If  he  gets  up  at  half-past  seven,  for  example,  give  him 
the  following  prescription  in  writing:  (a)  7.30  a.m. — Rise.  (&)  7.45  a.m. — 
Drink  a  glass  of  cold  water.  For  those  who  have  a  superstitious  reverence  for 
medication  give  an  infusion  of  quassia  prepared  the  evening  before,  (c)  S  a.-m. 
— Hearty  breakfast  with  milk,  coffee  or  tea,  according  to  choice,  and  even 
chocolate  for  those  who  are  not  constipated  by  this  food.     Use  bread  (Graham, 


TREATMENT    OF    CONSTIPATIOlSr.  .  217 

if  possible)  and  butter,  with  honey  or  preserves,  (d)  9  a.m. — Try  to  go  to 
the  toilet  at  a  fixed  hour.  '  Do  not  go  at  any  other  time  and  refuse  to  do  so, 
saying  to  your  intestine :  '  You  would  not  move  at  nine  o'clock ;  now  you  can 
wait  until  to-morrow !  '  (e)  Use  a  copious  diet,  giving  the  preference  to  vege- 
table foods. 

"  But  do  not  be  content  with  enumerating  these  measures  and  putting  them 
on  paper ;  explain  them,  comment  upon  them,  and  enumerate  the  '  invita- 
tions '  which  the  prescriptions  contain.  The  patient  will  reply  to  you :  '  But 
I  have  already  tried  to  go  at  a  fixed  hour.  I  have  already  taken  a  glass  of 
cold  water.' 

"  You  can  reply  to  him :  '  My  dear  sir,  six  cannons  can  make  a  breach 
where  one  or  two  are  not  enough.     Go  on  bravely  and  you  will  succeed !  ' 

"  And  last  of  all,  do  not  suppress  the  suggestive  effect  which  you  have  just 
produced.  An  excellent  confrere,  who  for  long  years  practised  this  treatment, 
told  me- that  he  was  well  satisfied  with  it,  but  that  he  had,  nevertheless,  had 
some  failures.  Astonished  at  this,  I  made  him  go  over  the  prescriptions  which 
he  had  given.  They  were  as  complete  as  though  I  had  dictated  them  myself. 
I  tried  to  find  the  cause  of  the  failure,  when  my  confrere  added :  '  However,  I 
have  never  discouraged  the  patient  and  I  have  told  him  if  this  does  not  work 
there  are  still  other  means !  '  This  counter-suggestion  was  sufficient  to  explain 
his  failures.  When,  one  wishes  to  convince  one  of  anything  it  does  not  do  to 
suggest  the  idea  of  possible  failure." 

Those  who  would  prevent  constipation  must  also  see  to  it  that  their  patient's 
diet  is  of  a  proper  sort,  not  too  highly  seasoned,  nor  of  concentrated  fancy  foods, 
and  not  too  much  meats,  but  sensible  amounts  of  simple,  bulky,  nutritious  arti- 
cles, such  as  are  constantly  found  on  the  table  of  the  farmer.  A  diet  largely 
vegetarian,  starchy  foods,  legumes,  coarse  bread,  fruits,  fresh  and  stewed,  all 
conspire  to  regulate  the  function  and  to  make  it  easy  of  performance. 

Let  me  enumerate  a  list  for  selection :  Oatmeal  and  various  breakfast  cereals 
with  cream.  Graham  bread,  rye  bread,  corn  bread,  bran  bread,  Boston  brown 
bread,  dry  Swedish  bread,  German  Schwarzbrod,  which  can  now  be  bought  in 
most  of  our  large  cities.  Plenty  of  fresh  butter  on  the  bread,  for  fats  generally 
help  to  relieve  constipation.  Honey  or  molasses  at  breakfast.  Soft  boiled  eggs, 
cabbage,  sauerkraut,  cauliflower,  lettuce  and  salads  of  all  kinds,  sj)inach,  peas, 
Lima  beans,  string  beans,  lentils,  carrots.  Fruits,  especially  stewed  prunes,  figs, 
and  plums ;  in  the  berry  season  all  berries  with  seeds  are  valuable  aids. 

The  best  beverages  are  plain  water  and  buttermilk. 

I  would  suggest  some  such  simple  regimen  as  this  to  start  with : 

A  glass  of  cold  water  on  rising. 
Breakfast : 

Oatmeal,  cream  of  wheat,  etc.,  with  cream.  Bread  with  plenty  of  but- 
ter; corn  bread,  or  corn  cakes,  or  Johnny  cake,  with  honey  or  mo- 
lasses ;  soft  boiled  eggs,  fish.     Weak  coffee,  buttermilk,  malted  milk. 


218  CO>;STIPATIOX.        HEADACHE.       INSOMNIA.       OBESITY. 

Lunch : 

A  little  cold  meat,  rice,  caviar,  sardines,  anchovies.    Potato,  string  beans, 
asparagus.     Salad.     A  simple  jmdding;  cheese  and  crackers;  baked 
apples. 
Dinner : 

A  thick  soup,  bread  or  cheese  straws.  Shell  fish.  Celery,  olives,  rad- 
ishes. White  or  sweet  potatoes  and  vegetables  of  all  kinds  ad  libi- 
tum.    Salad.     Xuts  ad  libitum.     Fruits.     Grape  juice. 

I  have  made  no  allowance  here  for  a  fashionable  dinner  in  many  courses. 

Some  people  find  that  an  apple  eaten  every  day  in  the  evening  or  in  the 
morning  regulates  the  function. 

Again  so  simple  a  device  as  a  glass  of  cool  water  in  the  morning  on 
rising  is  all  that  is  needed.  It  may  be  that  hot  water  is  more  agi-eeable  as  well 
as  more  acceptable  to  the  stomach.  A  glass  of  cool  water  containing  a  little 
lime  or  lemon  juice  is  often  more  effective.  Sometimes  patients  do  not  drink 
enough  water,  and  for  such  persons  a  glass  of  water  every  two  hours  between 
meals  should  be  prescribed.  An  invaluable  simple  medicament  acting  like  the 
natural  mineral  waters  is  the  phosphate  of  soda  taken  every  day,  a  tea- 
spoonful  in  a  glass  of  water  early  in  the  morning. 

Daily  exercise  is  a  prime  requisite.  Let  no  one,  adult  or  maiden,  think 
that  this  important  function  will  regulate  itself  if  they  simply  eat,  and  sit,  and 
talk,  and  dawdle  about.  Active  stimulating  exercise  is  imperative  ; 
a  good  long  walk  in  good  company,  golf,  horseback,  swimming, 
rowing,  or  at  a  pinch,  'pour  pis  aller,  home  gymnastics  in  the  fresh  air 
of  a  well  ventilated  room  with  the  windows  wide  open.  Equally  important  with 
general  muscular  exercise  is  the  care  of  the  skin  by  a  daily  cold  bath 
followed  by  rubbing  with  a  coarse  towel,  and  deep  breathing 
exercises    associated  with  the  regular  muscular  exercise. 

When  the  abdominal  muscles  are  lax,  especially  after  confinement,  they  can 
be  strengthened  by  lying  flat  on  the  back  and  rising  to  a  sitting  posture  by  the 
abdominal  muscles  alone  without  any  aid  from  the  hands  or  arms.  C  v.  Wild 
even  recommends  these  gymnastics  several  times  a  day  for  the  puerperal  patient 
from  the  tenth  to  the  twelfth  days  onwards. 

If  a  young  woman  will  discard  the  rigid  tight-fitting  corset  when  she 
beg'ins  to  take  exercise  adapted  to  making  her  breathe  deeper  and  strengthen 
her  loins,  she  will  have  taken  one  most  important  step  towards  regulating  this 
function. 

(2)  Galvano-f aradism. — This  form  of  treatment  is  recommended  by 
Erb  ("  Handbuch  der  Elektrotherapie  ").  The  galvano-f aradic  current  has 
proven  of  great  use  in  stimulating  the  atonic  bowel  into  normal  activity  and  in 
overcoming  chronic  constipation.  Brose,  who  writes  after  considerable  experi- 
ence, found  that  out  of  twenty-nine  cases  of  chronic  constipation  treated  by  this 
means  alone,  twenty-eight  were  relieved,  the  remaining  patient  giving  up  the 


TREATMENT    OF    CONSTIPATION.  219 

treatment  because  there  were  no  perceptible  results  after  five  sittings  ("  Die 
Behandlung  d.  chron.  Obstipation  mittels  d.  Galvano-farad.  Stromes,"  Fest- 
schrift zu  Prof.  Dr.  Meyer ^  Gottingen). 

Brose  used  a  strong  galvanic  current  of  from  fifty  to  seventy-five  milliam- 
peres  and  a  faradic  current  as  strong  as  tbe  patient  could  bear.  He  made  use 
of  large  electrodes  eight  by  eight  inches  in  size,  placing  the  positive  pole  on  the 
sacral  region  and  the  negative  on  the  abdomen.  The  sittings  averaged  from 
four  to  six  for  milder  degrees  of  the  condition,  to  thirty  or  forty  in  more  severe 
varieties. 

C.  V.  Wild  uses  the  same  remedy  somewhat  differently.  The  patient  lies 
upon  her  back  with  her  head  raised  a  little  and  with  knees  drawn  up.  She  rests 
upon  one  pole,  a  plate  nine  by  twelve  centimetres  (about  three  and  a  half  by 
five  inches)  while  a  round  electrode  is  used  on  the  anterior  abdominal  wall. 
The  anode  is  used  behind,  the  kathode  in  front.  The  current  employed  is  of 
a  strength  of  five  to  ten  milliamperes  and  is  given  by  pressing  the  electrode 
deep  into  the  walls.  Decided  contractions  of  the  muscles  in  the  abdominal  wall 
can  be  avoided,  if  necessary,  by  weakening  the  faradic  current.  That  current 
is  best  which  is  felt  to  excite  definite  peristaltic  contractions,  easily  recognized 
through  thin  walls.  The  sitting  lasts  about  five  minutes.  The  result  of  such  a 
treatment  is  often  prompt,  but  subsequent  treatments  are  needed  to  increase 
and  render  permanent  the  effect. 

Out  of  twenty-six  cases  treated  in  this  way,  twenty-four  are  noted  as 
cured,  while  two  gave  up  the  effort.  The  number  of  treatments  varied  from 
fifteen  to  one.  With  increasing  experience  the  worst  cases  were  relieved  in 
six  sittings. 

If  the  patient  will  not  regulate  her  diet  and  exercise,  nor  make  a  faith- 
ful attempt  to  evacuate  the  bowels  at  a  certain  hour,  adapting  her  diet  and 
beverages  to  encourage  this  regularity  of  habit,  then  nothing  remains  but 
to  resort  from  time  to  time  to  some  of  the  numerous  devices  all  of  which 
are  for  a  time  more  or  less  efficient.  The  worst  thing  that  can  be  done  is 
to  treat  a  case  of  constipation  by  simply  prescribing  as  the  ultimate  goal 
one  of  the  well  known  and  often  much  advertised  popular  remedies,  famil- 
iarly known  as  "  little  black  pills,"  French  grains,  or  by  their  initials  as 
A.  S.  &  B.  pills. 

Sanger,  in  a  most  earnest  appeal  (Centrhl.  f.  Gyn.,  1890,  vol.  14,  p.  349) 
insists  on  giving  up  all  these  common  medicaments,  which  as  he  declares, 
never  cure,  but  only  serve  to  fix  and  perpetuate  a  constipation,  forging  the 
chains  of  habit  upon  one  who  has  sought  the  physician  to  find  deliverance.  At 
the  utmost  these  vaunted  constipation  remedies  should  be  used  but  for  a  short 
time  for  temporary  effect  and  merely  as  expedients  on  the  way  to  better  things, 
namely,  the  cure  of  the  evil.  In  the  old  or  infirm,  wliere  hygienic  measures 
cannot  be  carried  out,  their  use  is  not  so  objectionable. 

For  such  a  purpose  cascara  sagrada  in  one  or  other  of  its  two  forms, 
namely,  the  solid  or  the  fluid  extract,  is  the  simplest  and  best  remedy. 


220  CONSTIPATION.       HEADACHE.       INSOMNIA.       OBESITY. 

1^  Ext.  cascarae  sagradae gr.  ij 

M.     Ft.  pil.  1. 

S.  Take  at  bedtime. 

Or 

^   n.  ext.  cascarse  sagradae  (aromat.) 
S.     Thirty  to  sixty  drops  at  bedtime. 

Little  pills  of   aloin   are  valuable  in  some  cases. 

1^  Aloin    gr.    -|- 

Strych.   sulph gr.  To" 

Ext.  bellad gr.  To" 

M.     et  ft.  pil.  1. 

S.       Take  at  bedtime. 

A  small  dose  of  podophyllin,  half  a  grain  or  less,  may  be  added  to  the  last 
prescription,  if  desired. 

For  patients  wbo  insist  upon  regulating  themselves  with  drugs,  the  whole 
gamut  of  the  pharmacopeia  may  be  rim,  for  no  one  remedy  or  prescription 
does  service  week  after  week.     For  such  I  mention  the  following : 

Rhubarb,    in  the  form  of  the  following  prescription: 

I^   Pulv.  rhei gr.   1^ 

Sod.  bicarb gr.   1^ 

Oil  peppermint gr-  to" 

M.     et  ft.  pil.  1. 

S.       Take  at  bedtime. 

Aloes  soc,  one-half  of  a  grain,  and  the  extract  of  nux  vomica,  one- 
sixth  of  a  grain,  may  be  added. 

Podophyllin  resin  in  pills  containing  one-twentieth  of  a  grain,  and 
compound  liquorice  powder,  in  doses  of  from  one  to  three  teaspoonfuls 
or  in  the  form  of  compressed  tablets,  are  good  remedies.  Calomel  is  the 
best  remedy  for  an  occasional  unloading,  say  once  in  ten  days.  A  single  dose 
of  three  to  five  grains  may  be  given  at  night  followed  by  a  saline  (Rochelle 
salts,  two  drachms)  in  the  morning.  Asafoetida  with  capsicum  is  said 
by  Anders  to  be  of  benefit  in  senile  atrophy  with  flatulence.  A  skilful  old 
practitioner  whom  I  knew  when  I  was  a  boy  prided  himself  on  a  mixture  of 
this  kind: 

^   Magnes.   sulph 3j 

Magnes.  carb 3ss. 

Inf.  gent,  comp 3ss. 

Aq.  menth.  pip Sjss. 

M.      S.   Shake  well  and  take  at  bedtime. 

The  advantage  of  this  prescription  is  that  there  is  no  danger  of  the  patient 
becoming  the  devotee  of  n  drug. 


TREATMENT    OF    CONSTIPATION,  221 

A  good  laxative  for  children  is  the  following  formula: 

^   Pulv.  rhei gr.  y  o" 

Sulphur    gr.  ^ 

Sod.  phos.  exsic gr.   1 

01.  menth.  pip TTt  -^ 

M.     et  ft.  pil.  1. 

S.      Take  at  bedtime. 

Senna   leaves   cooked   with   prunes    or   figs    and   made   into    a   paste    is 
readily  taken  by  children  and  is  effective. 

Massage  of  the  abdominal  muscles  is  one  of  the  best  means  at 
our  disposal,  especially  in  cases  where  outdoor  exercise  is  deficient.  A  metal 
ball  covered  with  leather,  and  weighing  four  to  six  pounds,  may  be  rolled 
over  the  abdomen  every  morning  for  five  to  ten  minutes  to  stimulate  peristalsis. 
The  simplest  of  all  adjuvants  are  the  natural  mineral  waters:  Friedrichs- 
hall,  Apenta,  Hunyadi,  Carlsbad  salts,  a  teaspoonful  in  a  glass  of  water  every, 
morning. 

If  the  constipation  is  of  long  standing,  it  is  well  to  give  a  laxative,  fol- 
lowed in  six  or  eight  hours  by  an  enema,  and  then  to  repeat  the  laxative  on 
one  or  two  successive  days  in  order  to  insure  a  complete  evacuation  of  the 
lower  intestinal  tract.  In  this  manner  the  sluggish  bowel  is  often  compelled 
to  yield  up  the  accumulation  of  weeks,  to  the  utter  astonishment  of  the  patient 
and  often  of  the  physician  as  well.  Such  a  course  is  imperative  in  preparing 
for  any  gynecological  operation.  If  it  is  neglected,  the  surgeon  may  have 
occasion  for  anxiety  for  several  days  after  the  operation,  until  the  bowels 
begin  to  move,  and  then  there  is  often  a  regular  debacle,  with  reports  of  one 
or  two  bedpans  filled  with  the  malodorous  materials,  when  the  depression 
vanishes,  the  temperature  and  pulse  drop,  and  the  facies  change  from  a  sallow 
pinched  expression  to  a  natural  one. 

In  the  preparation  for  operations  upon  complete  laceration  of  the  perineum 
and  sphincter  ani,  it  is  my  custom  to  give  compound  liquorice  powder 
in  doses  of  three  to  six  teaspoonfuls. 

Enemata. — These  are  perhaps  the  simplest  and  safest  means  of  unload- 
ing the  bowel  and  avoiding  drugs.  In  cases  where  the  extreme  lower  bowel 
is  habitually  loaded  and  there  seems  to  be  a  lack  of  expulsive  power,  I  find  it 
efficacious  to  inject  from  two  to  six  ounces  of.  warm  sweet  oil,  passed 
slowly  in  with  a  soft  catheter  at  a  slight  elevation  at  bedtime.  It  ought  to 
act  naturally  the  next  morning.  A  glycerin  suppository  is  sometimes 
efficacious  in  the  same  way.  Large  enemata  of  warm  sweet  oil  from  a 
half  to  one  pint,  introduced  slowly  and  gently,  have  been  used  in  Germany 
with  success.  The  action  here  is  upon  the  upper  colon  as  well  as  the  lower 
bowel.  Sweet  oil  taken  freely  by  the  mouth  at  meals  with  food,  or  taken 
deliberately  as  a  laxative  (tablespoonful)  at  meal  times  has  corrected  the  habit 
-in  some  instances. 


222  CONSTIPATIOX.        HEADACHE.       INSOMNIA.       OBESITY. 

Of  the  watery  euemata  tlie  flaxseed  enema  is  tlie  best.  I  make  it  by 
taking  two  tablespoonfnls  of  flaxseed  to  a  pint  of  cold  water,  boiling  it  for 
ten  minutes,  and  then  straining  out  the  seeds.  The  whole  shonld  be  injected 
while  still  warm  (not  hot!),  and  should  be  of  a  mucilaginous  consistency.  A 
simple  emulsion  is  made  of  cotton-seed  oil,  with  enough  soap  and 
warm  water  to  make  up  a  pint.  A  satisfactory  purgative  enema  is  com- 
posed of  sulphate  of  magnesia  (Epsom  salts)  four  ounces,  glycerin 
two  ounces,  turpentine  two  drachms,  and  warm  water  four  ounces. 
This  enema  is  always  effectual,  but  it  may  be  exhausting  to  a  weak  patient. 
I  often  use  it  without  the  turpentine. 

Caution :  A  too  frequent  use  of  large  enemata  may  distend  the  lower  bowel, 
cause  loss  of  tone,  and  so  increase  the  difficulty  it  is  attempting  to  overcome. 
When  the  constipation  is  associated  with  torpidity  of  the  liver,  small  doses 
of  calomel  must  be  given  from  time  to  time,  followed  by  a  saline.  A 
broken  dose  of  calomel,  consisting  of  one-eighth  of  a  grain  given  every  half 
hour  for  eight  doses,  is  the  best  way  to  administer  it,  with  a  glass  of  Apenta 
water  next  morning. 

In  all  obstinate  constipation  coming  on  in  middle  life,  bear  in  mind  the 
possibility  of  malignant  disease  of  the  intestine,  or  the  pressure  from 
pelvic  tumors,  or  a  stricture  ;  these  can  be  detected  by  a  local  exam- 
ination either  with  the  finger  or  with  one  of  Kelly's  proctoscopes. 

In  a  woman  who  has  borne  children  and  in  whom  the  vaginal  outlet  is  lax 
and  gaping,  a  pouting  and  eversion  of  the  vaginal  walls,  especially  the  pos- 
terior wall  (rectocele),  is  often  seen,  if  the  patient  is  told  to  press  down.  In 
these  cases  a  suitable  operation  repairing  the  outlet  often  does  much  to  relieve 
the  difficulty  of  evacuation  by  restoring  the  muscular  and  tendinous  structures, 
so  that  the  pressure  in  the  act  of  defecation  is  no  longer  lost  in  the  vagina, 
but  acts  instead  on  the  rectal  sphincter. 

The  care  of  the  bowels  immediately  after  abdominal  opera- 
tions is  a  matter  for  much  care  and  decision,  and  as  it  sometimes  happens 
that  this  duty  is  left  to  the  lot  of  the  physician  in  charge  of  the  case  by  the 
operator,  I  give  some  general  directions  in  regard  to  it.  If  the  bowels  are 
thoroughly  moved,  as  they  should  be,  before  the  operation  is  performed,  they 
need  not  act  again  until  the  second,  or  even  the  third  day.  This  first  action 
is  best  accomplished  by  means  of  the  flaxseed  enema  described  above, 
and  when  the  bowels  have  been  once  opened,  there  should  then  be  an  action 
every  twenty-four  hours.  A  special  enema,  which  I  have  found  useful  in  some 
cases,  is  composed  of  cotton-seed  oil,  four  ounces,  glycerin,  two  ounces, 
turpentine,  two  drachms,  and  enough  soap  and  water  to  make  up  a  pint. 
For  distention  with  constipation  following  operations  I  have  found  milk  of 
asafoetida,  four  to  eight  ounces,  used  warm,  very  effectual.  As  no  exer- 
cise can  be  taken,  some  form  of  assistance  may  be  necessary  to  keep  the  bowels 
open  eacb  day.  Cascara  is  the  best  drug  for  this  purpose,  but  it  may  be 
made  a  general  rule  that  lar2:e  doses  of  a  laxative  medicine  should  never  be 


TEEATMENT    OF    CONSTIPATION.  223 

given  to  a  patient  lying  on  her  back  and  obliged  to  evacuate  the  bowels  in  that 
position.  Unless  a  mild  dose  of  eascara  (forty  to  sixty  drops  of  the  aroma- 
tized fluid  extract)  is  sufficient,  it  is  best  to  continue  the  flaxseed  enemata  as 
long  as  the  patient  remains  in  bed. 

Sanger,  v^ho  has  been  largely  followed  in  his  own  country,  lays  great  stress 
on  some  such  plan  of  procedure  as  the  following:  In  the  first  place,  the  work- 
ing principle  is  to  wean  the  patient  as  soon  as  possible  from  all  drugs.  To  do 
this  it  is  necessary  to  win  her  confidence  completely,  both  as  to  the  importance 
of  the  undertaking  and  the  ability  of  the  physician  to  effect  a  cure.  At  first 
a  few  drugs  are  used  to  tide  over  the  difficult  period  of  breaking  off,  but  later 
even  these  are  given  up  absolutely,  until  finally  nothing  but  a  little  bella- 
donna is  used,  and  that  only  occasionally.  Cascara,  Sanger  considers  no 
better  than  any  other  purgative.  After  giving  up  laxatives  in  this  way  a 
period  of  persistent  constipation  follows,  which  may  last  for  eight  days  or 
longer.  This  should  be  explained  to  the  patient  beforehand,  and  she  should 
be  assured  that  nature  will,  in  time,  take  care  of  the  difficulty.  Sanger  uses 
no  special  diet,  declaring  that  "  no  diet  is  the  best  diet."  It  is,  however, 
important  to  see  that  several  glasses  of  water  are  taken  daily,  or  else 
whey,  buttermilk,  or  sour  milk.  Fresh  and  cooked  fruits  are 
used  as  well  as  coarse  bread.  In  addition  to  this  an  attempt  at  regularity 
of  habit  is  enforced.  Most  important  is  some  daily  active  exercise, 
especially  in  the  gymnasium.  Injections  are  used  to  as  limited  an  extent 
as  possible;  and  purgative  mineral  waters  are  rejected  (ich  halte  dieselben 
(Brunnencuren)  geradezu  filr  werthlos).  Most  important  of  all  methods  in 
the  treatment  is  the  massage  of  the  abdomen  associated  with  the 
use    of   electricity,    especially  in  lax  abdomens. 

This  plan  has  proved  successful  in  the  hands  of  one  of  the  most  eminent 
gynecologists  Germany  has  yet  produced.     I  give  it  again  here  in  outline: 

1.  'No  medicines  except  a  little  belladonna  occasionally. 

2.  Let  the  patient  remain  constipated,  if  necessary,  for  over  a  week. 

3.  In  the  meantime  use  ordinary  diet  with  the  addition  of  fruits. 

4.  See  that  she  takes  plenty  of  water  between  meals. 

5.  See  to  it  that  some  active  exercise  is  taken. 

6.  Use  abdominal  massage. 
Y.  Use  abdominal  electricity. 

8.  Encourage  in  the  meantime  a  regular  habit  by  waiting  upon  nature  at 
a  fixed  time. 

By  these  simple  means  an  obstinate  constipation  habit  may  be  overcome. 


224  CONSTIPATION.        HEADACHE.       INSOMNIA.       OBESITY. 


HEADACHE. 

Headache  is  perhaps  the  commonest  of  all  the  ills  that  flesh  is  heir  to. 
It  is,  indeed,  an  ailment  so  frequent  that,  as  a  rule,  it  arouses  no  attention 
nor  does  it  excite  any  solicitude  as  to  the  welfare  of  the  patient.  jSTeverthe- 
Jess,  headaches,  to  those  who  suffer  from  them,  are  an  aggravating  and  dis- 
tressing disorder,  often  robbing  life  of  its  zest  and  sweetness  and  liable  at  any 
time  to  interfere  with  plans  of  enjo^Tiient  or  occupation.  Repeatedly  recurring 
headaches  are  peculiarly  hard  to  bear,  and,  if  not  relieved,  may  render  life 
a  burden. 

A  headache  is  nothing  more  or  less  than  a  symptom,  which  often  leads  up 
through  a  tangled  skein  to  some  remote  and  unexpected  disorder.  Persistent 
headaches,  however,  are  often  most  difficult  to  relieve,  so  that  the  sufferer 
goes  from  one  physician  to  another,  tries  all  manner  of  patent  medicines,  and, 
as  a  rule,  sooner  or  later  consults  a  variety  of  specialists  to  see  if  some  master 
in  his  own  department  cannot  detect  an  abnormality  which  is  the  cause  of  the 
continued  pain.  After  the  general  practitioner,  the  stomach  specialist  may  be 
consulted,  and  he,  finding  a  trifling  subacidity,  prescribes  hydrochloric  acid; 
this  fails  to  bring  relief,  and  as  the  patient  hears  of  some  brilliant  cures 
wrought  by  the  oculists,  she  goes  to  the  nearest  one  of  repute,  who  finds  a 
mild  astigmatism  and  prescribes  glasses,  which  also  fail  to  relieve.  She  then 
consults  a  gynecologist,  feeling  sure  that  the  secret  of  the  recurring  suffering 
must  lie  concealed  in  those  mysterious  pelvic  organs  which  control  the  cycles 
of  her  life  from  childhood  to  old  age.  The  gynecologist,  in  turn,  finds  a  slight 
uterine  deviation  from  the  normal,  and  puts  in  a  pessary,  after  which  she  is 
either  resigTied  to  her  fate,  or  becomes  addicted  to  morphin,  or  some  of  the 
many  dangerous  patent  medicines,  advertised  ^rith  superb  impudence  not  to 
kill  but  to  relieve  suffering.  It  is  because  so  many  of  these  patients  with 
headaches  apply  sooner  or  later  to  the  gynecologist,  that  I  have  felt  it  important 
to  say  a  few  words  upon  the  subject. 

Frequency. — I  have  investigated  the  frequency  with  which  headaches  occur 
in  connection  with  pelvic  and  abdominal  disorders,  by  going  over  five  hundred 
entries  in  my  case-books,  and  I  find  that  one  hundred  and  seven  of  the  five 
hundred  suffered  from  headache  of  one  kind  or  another,  in  different  degTees 
of  severity ;  in  thirty-two  cases,  the  headaches  were  associated  with  the  men- 
strual period. 

Etiology. — He  who  would  treat  headaches  successfully,  must  in  every  case 
look  deej^er  than  the  throbbing,  aching  head,  and  search  for  the  underlying 
cause  or  causes.  Indeed,  it  is  chiefly  in  this  way  that  the  intelligent  and 
trained  practitioner  differs  from  the  quacks  who  advertise  their  nostrums  in 
the  daily  papers.  While  the  practitioner  investigates  and  removes  causes  and 
so  often  cures  the  ailment,  the  parasite  upon  the  profession  treats  all  cases 


ETIOLOGY    OF    HEADACHE.  225 

alike,  considers  headaclie  a  disease  per  se,  and  for  the  sake  of  his  ten  or  twenty 
cents'  gain  supplies  a  remedy  which  he  swears  will  cure  the  malady,  in  reality 
giving  temporary  relief  only  by  benumbing  the  brain.  This  he  does  even  at 
the  risk  of  life  itself,  without  any  conscience  at  all,  trusting  to  the  lax  admin- 
istration of  our  criminal  laws,  if  he  should  be  arraigned  for  murder.  The 
nostrum  vender  is  thus  on  a  par  with  those  brutal  savages  who  waylay  and 
slay  their  hapless  victim  for  the  purpose  of  stealing  so  trifling  an  article  as 
his  penknife  or  a  few  pennies  in  his  pocket. 

In  undertaking  to  treat  rationally  and  successfully  the  cases  of  headache 
which  come  to  me  as  a  gynecologist,  I  must  keep  in  mind  all  the  various  com- 
moner causes  of  the  ailment,  lest  I  make  the  mistake  so  often  attributed  to  a 
specialist,  namely,  that  of  seeing  only  my  own  little  territory,  and  considering 
that  all  humanity's  ailments  in  one  way  or  another  must  flow  from  the  pelvis. 

In  treating  headaches  in  women,  I  note  in  the  first  place,  that  men  are 
relatively  free  from  this  affection  to  a  remarkable  degree,  and  that  when  men 
do  suffer  from  headaches,  they  are  apt  to  arise  from  overindulgence  at  the 
table ;  in  such  a  case  the  ache  of  the  next  day  is  clearly  gastric  in  its  origin. 
Furthermore,  the  severe  and  lasting  headaches  of  men  about  middle  life  are 
sometimes  the  premonitors  of  grave  organic  disorders,  as,  for  example,  Bright's 
disease.  I  discern  from  these  facts  that  two  forms  of  toxemia,  a  tran- 
sient and  a  permanent  form,  are  at  work,  and  that  it  must  be  the  toxic  by- 
products in  the  blood  which  produce  the  symptom,  headache.  I  note,  too, 
that  a  whole  group  of  headaches,  often  seen  in  women,  the  nervous  head- 
aches, are  conspicuously  infrequent  in  men.  A  little  further  thought  sug- 
gests, what  is  quite  certainly  true,  that  the  reason  for  this  difference  lies  in 
the  less  active  physical  and  intellectual  life  of  the  woman,  and  at  once  fur- 
nishes valuable  ideas  as  to  treatment.  If  this  is  true  there  ought  to  be  less 
headache  among  our  college  women  than  among  those  who  go  out  at  once  into 
society  life. 

I  think  we  shall  not  go  far  wrong  if  we  classify  most  of  our  cases  of  head- 
aches under  one  or  other  of  the  following  headings : 

Toxic,  those  due  to  ptomaine,  or  leucomaine  poisonings  (uric  acid,  etc.), 
to  fevers,  to  Bright's  disease,  constipation,  and  various  intestinal  disorders,  etc. 

ISTeurasthenic,  those  associated  with  the  nerve  exhaustions,  so  common 
in  our  women  to-day. 

Vaso- motor,  congestive  and  unilateral  headaches,  often  associated  with 
neurasthenia,  but  frequently  noted,  too,  in  women  in  robust  health. 

Anemic,  a  cry  of  the  brain  for  food,  like  the  pain  in  over-tired  muscles. 
The  headaches  of  children  at  school,  while  often  ocular,  are  sometimes  but  the 
cry  of  a  tired,  over-worked,  often  underfed  organ,  which  ought  to  lie  fallow 
while  the  rest  of  the  body  is  undergoing  its  evolution  towards  adult  life. 

Reflex,   from  the  eye,  nose,  or  frontal  sinus. 

Hereditary,    in  cases  where  often  no  other  cause  can  be  assigned.     In 

migraine   it  is  frequently  the  only  explanation  which  can  be  offered. 
16 


226  coisrsTiPATioN.     headache,     insomnia,     obesity. 

Brain  disease,  as  in  syphilis  and  meningitis,  traumata  and  brain 
tumors. 

In  the  investigation  of  a  particuhir  case,  the  j)hysician  must  try  to  trace 
it  up  to  one  of  these  groups,  and  then  to  analyze  the  particular  causes  there 
operative. 

The  first  step  is  to  inquire  as  to  the  frequency  of  the  headache,  its 
intensity,  its  duration,  and  its  relation  to  the  menstrual  period. 
Menstrual  headaches  are  vaso-motor  in  origin  (I  do  not  believe 
they  are  toxic)  ;  as  a  rule,  the  premenstrual  form  is  relieved  when  the 
flow  appears  and  the  menstrual  form  when  a  sufficient  flow  is  established. 
I  have  not  found  any  particular  association  between  pelvic  affections  and  the 
especial  variety  of  headache  which  occurs  on  the  top  of  the  head ;  in  my  expe- 
rience the  sincipital  headache  is  rare. 

Patients  with  nerve  exhaustion  are  apt  to  suffer  from  a  dull  j)ain  or 
pressure  in  the  back  of  the  head  and  the  upper  part  of  the  spine.  Intense  and 
persistent  headache  is  one  of  the  commonest  symptoms  among  neurasthenics. 
Headache  due  to  eyestrain  is  apt  to  be  frontal  in  character.  Where  any 
symptoms,  such,  for  example,  as  eye-tire,  point  to  the  eye,  and  where  other 
avenues  of  inquiry  have  been  exhausted,  it  is  always  Avell  to  call  upon  a  com- 
petent ophthalmologist  for  his  opinion. 

!N^asal  polyps  may  give  the  first  evidence  of  their  presence  in  the  severe 
headaches  they  provoke.  A  little  difficuity  in  breathing,  especially  if  it  is 
marked  at  the  time  of  the  headache,  should  call  for  an  examination  of  the 
upper  respiratory  passages.  Frontal  sinus  disease  may  in  like  maimer 
occasion  intense  pain  in  the  head  with  local  and  supra-orbital  tenderness. 

It  must  never  be  forgotten  that  headache  is  sometimes  a  marked  symptom 
of  malaria,  or  of  typhoid  fever  in  its  incipiency  ;  such  cases  are 
occasionally  seen  in  the  wards  of  a  large  hospital.  A  routine  examination  of 
the  blood  is  of  great  service  in  such  instances.  Anemia  is  sometimes  the 
self-evident  cause  of  headache,  particularly  in  women  who  have  lost  much 
blood  by  uterine  hemorrhages.  Many  grades  of  anemia  can  only  be  recognized 
by  the  hemaglobinometer,  an  instrument  so  simple  that  it  ought  to  be  in  the 
hands  of  every  practitioner  advanced  enough  to  consider  it  important  to  use 
a  thermometer  in  his  daily  practice. 

In  severe  nocturnal  headaches,  syphilis  must  always  be 
looked  for. 

In  the  headache  of  Bright's  disease  the  increase  of  arterial 
tension  is  often  evident  in  the  hard  bounding  pulse;  the  tension  is  easily 
measured  with  one  of  the  simple  mercury  pressure  instruments  connected  with 
a  constricting  band  on  the  arm  (the  Riva-Bocci,  or  one  of  its  derivatives). 

Some  patients  date  their  severe  headaches  from  an  over-exposure  to  the 
heat  of  the  sun  (insolation),  producing  a  profound  vaso-motor  disturbance, 
after  which  the  least  exposure  or  fatigue  serves  to  bring  on  a  violent  attack. 

In  reviewing  the  history  in  a  puzzling  case,    heredity   must  receive  close 


ETIOLOGY    OF    HEADACHE. 


227 


attention,  as  it  may  be  the  only  assignable  cause.  Dr.  Ira  J.  Prouty,  of  Keene, 
]Sr.  H.,  tells  me  the  case  of  a  professor  in  a  college,  who  graduated  in  medicine 
and  then  had  to  give  np  the  idea  of  practising,  because  he  suffered,  as  did  his 
father  before  him,  from  severe  headaches  every  two  weeks.  I  find  it  always 
well,  too,  to  inquire  as  to  any  severe  trauma  to  the  head,  received  perhaps 
in  childhood,  and  in  case  there  is  such  a  history,  to  ask  the  opinion  of  a  good 
nerve  specialist. 

Habits  of  food  and  habits  of  drinking  must  be  looked  into,  espe- 
cially the  latter  in  these  days.  Many  headaches  are  alcoholic  and  grow 
worse  as  the  patient  continues  to  imbibe  the  poison.  With  men,  tobacco  is 
a  potent  cause  and  in  certain  ranks  of  society  to-day,  this  factor  needs  con- 
sideration in  treating  women. 

After  reviewing  in  this  manner  the  various  possible  causes  of  headaches, 
and  excluding  any  possible  unusual  cause,  the  physician  can  settle  down  to  a 
minute  and  careful  investigation  of  those  causes  which  are  most  commonly 
operative  in  women,  one  or  more  of  which  is  usually  at  work  in  any  given  case. 

Auto-intoxication  from  the  gastro-intestinal  tract  due  to  fer- 
mentation of  food  must  always  be  thought  of  and  eliminated  by  questioning, 
or,  if  there  is  any  doubt,  it  must  be  settled  by  washing  out  the  stomach  and 
analyzing  its  contents.  The  question  of  fermentation  in  the  tract  lower 
down  must  always  be  considered.  This  is  most  apt  to  be  noticed  after  opera- 
tions, when  it  often  simulates  an  incipient  peritonitis. 

Constipation  is  perhaps  the  most  fruitful  of  all  causes  of  headache, 
and  it  is  all  the  more  insidious  because  women  become  so  habituated  to  the 
condition  of  sluggish  bowels,  that  they  fail  to  realize  the  importance  of  its 
bearing  upon  their  general  health.  A  vaginal  examination  often  reveals  a 
fulness  of  the  bowel,  surprising  to  the  patient  who  "  has  just  had  an  action." 
The  finger  feels  a  bolus  through  the  posterior  vaginal  wall,  and  often  there 
are  a  number  of  tender  masses  (scybalse)  above  the  vault  w^hich  may  mislead 
a  neophyte  into  proposing  an  abdominal  operation. 

Potent  among  the  causes  of  headache  in  women  is  domestic  infelicity. 
An  unfaithful  or  an  unkind  husband  works  like  a  carking  care  on  the  nervous 
system,  robbing  life  of  all  its  spontaneity  and  joy.  The  poor  victim  gives  up 
her  friends,  she  soon  ceases  to  take  any  active  exercise,  and  mopes  about  the 
house ;  feeble  appetite,  indigestion,  and  anemia  follow,  and  the  foundation  is 
Avell  laid  for  regularly  recurring  severe  headaches. 

The  late  Prances  Power  Cobbe  has  given  an  able  description  of  this  form 
of  headache  in  an  article  entitled  "  The  Little  Health  of  Ladies  "  (LittelVs 
Living  Age,  Peb.  2,  1878).  "It  is  many  years,"  she  says,  "since,  in  my 
early  youth,  I  was  struck  by  a  singular  coincidence.  Several  of  my  married 
acquaintances  were  liable  to  a  peculiar  sort  of  headache.  They  were  obliged, 
owing  to  these  distressing  attacks,  to  remain  very  frequently  in  bed  at  break- 
fast time  and  later  in  the  day  to  lie  on  the  sofa  with  darkened  blinds  and 
a  considerable  exhibition  of  eau-de-cologne.     A  singular  immunity  from  the 


228  CONSTIPATIOX.       HEADACHE.       IXSOMI^IA.       OBESITY. 

seizures  seemed  to  be  enjoyed  Avlieu  any  pleasant  society  was  expected  or  tlieir 
husbands  happened  to  be  in  a  different  part  of  the  country.  By  degrees,  put- 
ting my  little  observations  together,  I  came  in  my  own  mind  to  call  these  the 
'  bad  husband  headaches,'  and  I  have  since  seen  no  reason  to  alter  my  diag- 
nosis. On  the  contrary,  I  am  of  opinion  that  an  incalculable  amount  of  female 
invalidism  arises  from  nothing  but  the  depressing  influence  of  an  unhappy 
home.  Sometimes,  of  course,  it  is  positive  unkindness  and  cruelty  that  the 
poor  creatures  endure.  Much  more  often  it  is  the  mere  lack  of  affection  and 
care  and  tenderness  for  which  they  pine  as  sickly  plants  for  sunshine.  Some- 
times it  is  the  oppression  of  an  iron  will  over  them  which  bruises  their  pleasant 
fancies,  and  lops  off  their  innocent  whims  till  there  is  no  sap  left  in  them  to 
bud  or  blossom  any  more.  I^ot  seldom  the  misery  comes  from  frequent  storms 
in  the  household  atmosphere — for  which  the  woman  is  probably  as  often  to 
blame  as  her  companion,  but  from  which  she  suffers  doubly,  since,  when  they 
have  passed,  he  goes  out  to  his  field  or  his  merchandise,  with  what  spirits  he 
can  muster,  poor  fellow,  while  she  sits  wherever  the  blighting  words  fell  on 
her  to  feel  all  their  bitterness.  ...  To  those  who  can  get  up  and  walk  away 
the  importance  which  she  attaches  to  them  seems  inexplicable." 

In  some  cases,  however,  the  fault  lies  in  a  self-centered  or  evil  disposition 
with  outbreaks  of  bad  temper  and  tantrums,  or  long  periods  of  sullen  brood- 
ing over  fancied  wrongs.  One  of  the  most  distressing  forms  of  headache  is 
that  induced  by  constant  weeping. 

The  wise  physician  who  is  the  friend  of  the  patient,  as  well  as  her  medical 
adviser,  will  always  in  puzzling  cases  squint  with  one  eye  in  this  direction, 
and  will,  where  his  advice  is  called  for,  treat  the  moral  as  well  as  the  physical 
ailments  of  the  family. 

Is  the  patient  a  neurasthenic  ?  If  she  is,  the  physician  must  expect  head- 
ache as  one  of  the  expressions  of  the  deficient  nerve  capital. 

In  addition  to  the  headaches  just  enumerated  we  have  the  simple  nervous 
headache  and  the  sick  headache,  or  migraine.  Various  explanations 
have  been  given  of  the  latter,  but  none  are  satisfactory.  Edward  Liveing, 
who  has  written  exhaustively  on  the  subject,  considered  the  attacks  to  be  nerve 
storms  nearly  related  to  epilepsy,  that  is  to  say,  a  form  of  periodic  discharge 
from  certain  sensory  centres :  a  picturesque  way  of  summarizing  the  phenom- 
enon, if  not  an  adequate  explanation.  Observations  made  by  Mangelsdorf  of 
Kissingen  show  that  in  every  case  of  migraine  there  occurs  a  well-marked 
acute  dilatation  of  the  stomach,  and  that  a  frequent  repetition  of  these  dila- 
tations leads  to  a  permanent  gastric  atony.  Mangelsdorf  claims  to  find  these 
same  dilatations  in  epileptics  during  the  attacks,  which  would  be  another  point 
in  evidence  of  close  resemblance  between  epilepsy  and  migraine.  Other 
authors  regard  sick  headaches  as  a  va so-motor  neurosis  and  support  this  view 
by  the  fact  that  during  the  attacks  the  temporal  artery  on  the  affected  side 
sometimes  becomes  hard  and  firm,  as  in  arteriosclerosis. 

There  can  be  no  doubt  that  sick  headaches  frequently  depend  upon  gastro- 


DIAGNOSIS    OF    HEADACHE.  229 

intestinal  disturbance.  W.  P.  Millspaugh  {South.  Calif.  Practitioner,  1907, 
vol.  22,  p.  513)  points  out  that  migraine  must  be  distinguished  from  another 
class  of  cases  in  which  headache  is  frequently  occasioned  by  disturbance  of 
the  gastric  secretion,  whereas  in  migraine  the  headache  and  the  gastric  dis- 
turbance are  in  all  probability  due  to  a  common  cause,  which,  according  to 
some  persons,  is  uric  acid  or  one  of  its  near  relatives  among  the  incompletely 
oxidized  end-products  of  nitrogen  metabolism.  In  the  former  class  of  cases 
there  is  hypersecretion  of  gastric  juices,  while  in  migraine  the  secretion  is 
diminished.  In  ordinary  hyperchlorhydria  the  correction  of  the  hyperacidity 
will  often,  according  to  Millspaugh,  relieve  the  headache,  and  he  suggests  that 
such  headaches  may  be  reflex  from  the  irritation  of  the  stomach  induced  by  the 
excess  of  hydrochloric  acid.  In  some  of  the  cases  of  the  kind  coming  under 
his  own  observation,  however,  he  was  inclined  to  suspect  that  the  alkalis  used 
to  correct  the  acidity  were  effective  by  checking  a  gouty  poison  which  might 
have  been  the  real  cause  of  the  whole  trouble. 

Diagnosis. — In  undertaking  a  patient  complaining  of  headache  I  would,  in 
the  first  place,  distinguish  whether  the  headaches  were  those  incidental  to  some 
other  well-defined  trouble  and  not,  as  a  rule,  intense.  If,  for  example,  the 
patient  is  anemic  from  the  loss  of  blood  from  the  uterus,  I  would  expect  the 
symptom,  headache,  to  disappear  with  the  correction  of  the  local  disorder.  I 
would  place  in  a  different  category  those  intense  headaches  where  the  distress 
in  the  head  overshadows  whatever  other  ailments  there  may  be,  and,  if  I  have 
determined  that  the  case  under  treatment  is  one  of  that  kind,  devote  myself 
at  once  to  the  minute  examination  of  every  function  of  the  body  to  discover 
the  cause. 

It  would  be  well  to  fill  in  some  such  outline  as  the  one  given  on  page  230, 
as  a  good  starting  point  to  clear  the  way  for  further  investigation. 

Usually  the  diagnosis  of  a  case  of  headache  involves  the  discovery  of  a 
variety  of  causes,  all  of  which  conspire  to  reduce  the  health  below  the  average 
norm,  when  the  headache  becomes  the  natural  cry  of  the  brain  for  more  and 
better  nutrition.  Tor  example,  a  nervous,  tired,  anemic  woman  enters  my 
office  with  a  dysmenorrhea,  or  with  a  descensus  and  dragging  of  the  pelvic 
organs,  associated  with  poor  appetite,  lack  of  exercise,  and  sleepless  nights ; 
in  such  a  case  I  expect,  as  a  matter  of  course,  to  hear  that  the  patient  also 
has  headaches,  and  in  undertaking  to  treat  the  general  condition  and  the  local 
pelvic  ailment,  I  expect  the  headaches  to  disappear  as  the  health  improves. 

Treatment. — The  treatment  of  headache  is  twofold :  that  designed  to  give 
immediate  relief;  and  that  looking  towards  the  removal  of  the  cause  and  the 
prevention  of  the  recurrence  of  the  pain.  It  will  be  well  to  glance  briefly  at 
the  kinds  of  treatment  we  have  at  our  disposal  before  taking  up  the  use  of  the 
particular  remedy  in  any  special  case. 

1.  In  the  first  place  there  are  those  remedies  which  promptly  and 
efficiently  remove  the  temporarily  acting  cause,  as  in  a  toxic 
headache  from  gastro-intestinal  fermentation.      Such  a  remedy  is    calomel, 


230 


CONSTIPATION,       HEADACHE.       INSOMNIA.       OBESITY. 


Name 


Age 


Married 


Children 


Miscarriages 


Menstrual  function  :    regularity  duration 

pain  relation   to   headaches  ? 

Headache  age  first   noted? 

growing  worse  ?  location   of  pain  ? 

character   of  pain  ?  average  duration  ? 

what  remedies   used  to  relieve  ? 


amount 


Associated  pheno?nena  ? 

eyes 

flushing  of  face  or  pallor 
nausea   and  associated  stomach   symptoms 
character  of  food  taken 
digestion 
sleep 
anemia 
urine 
other   ailments  ? 

amount  of  exercise? 

habit   as   to   bath 

character   of  home   life^   cheerful? 

any   evidences   of  yieurasthenia  ? 


any    illness  font   ivhich  headaches   date  ? 


TREATMENT    OF    HEADACHE.  231 

given  in  three  to  eight  grain  doses,  followed  by  a  saline  purge,  in  the 
form  of  Rochelle  salts,  the  citrate  of  magnesia,  or  Carlsbad 
salts,  some  six  or  eight  hours  later;  the  good  old  blue  mass  pill,  given 
in  doses  of  six  to  ten  grains,  is  too  much  out  of  vogue.  Sometimes,  where  the 
table  is  at  fault,  emesis  and  lavage  are  the  best  immediate  means  of 
giving  relief .    In  milder  cases,  powders  of  calomel  and   soda  may  be  given. 

I^   Hyd.  chl.  mit gr.  ^ 


M.     et  ft.  ch.  1.     Mitte  tales  no.  viii. 

Sig.     Take  one  powder  every  half  hour  until  bowels  move  and  head 
is  relieved. 

Some  persons  get  better  results  from  a  single  dose  of    calomel,    two  to  three 
or  five  grains. 

2.  Then  there  are  the  remedies  which  act  by  relieving  conges- 
tion. Such  are  blood  letting,  drawing  six  to  eight  ounces  from  the 
median  vein  of  the  forearm;  the  use  of  hot  baths,  hot  water  being  added 
after  the  patient  gets  in,  until  it  is  as  hot  as  she  can  bear;  hot  mustard 
hip  baths,  and  hot  mustard  foot  baths,  putting  about  a  tablespoonful 
of  Coleman's  ground  mustard  to  the  gallon  of  water.  The  amount  of  mustard 
must  depend  a  little  on  the  sensitiveness  of  the  patient's  skin. 

Counter-irritation  over  the  upper  part  of  the  spine  is  some- 
times a  great  relief.  A  mustard  plaster  may  be  tried,  or  chloroform 
liniment  laid  on  flannel  and  held  close  over  the  upper  cervical  vertebrse  as 
long  as  it  can  be  borne.  I  have  known  a  case  in  which  great  relief  was  experi- 
enced from  painting  the  upper  part  of  the  spine  with  the  tincture  of  iodine. 
In  some  forms  of  nervous  headache,  when  the  face  is  flushed  and  the  temples 
throbbing,  an  ice-bag  over  the  occiput  or  the  frontal  region  is  more 
beneficial,  or  cold  compresses,  made  by  holding  wet  towels  on  ice  and 
laving'  them  around  the  head  from  time  to  time. 

3.  Remedies  which  act  by  toning  up  the  nervous  system.  Here 
first  and  foremost  come  hygienic  measures,  such  as  the  morning  cold 
plunge,  with  lively  friction  to  the  skin;  massage;  electricity,  either 
applied  generally,  or  to  the  scalp  during  a  headache.  Gentle  frictions  to 
the  scalp  of  ten.  exercise  a  sedative  influence,  lessening  or  dissipating  the  pain. 
A  high-frequency  current  in  the  form  of  a  brush  discharge,  and  the  wave 
current  of  static  electricity  are  much  used  as  a  general  nerve  tonic  in  the 
intervals. 

4.  Hygienic  Means. — Regular  exercise  in  the  fresh  air,  par- 
ticularly breathing  exercises,  expanding  the  chest  and  quickening  the  circula- 
tion. If  the  patient  is  not  Aveak,  it  is  well  to  exercise  to  the  sweating  point, 
then  to  take  a  cold  sponge,  and  rest  for  half  an  hour  to  an  hour.  It  is  impor- 
tant for  patients  needing  hygienic   treatment  to  sleep  in  a  room  with  open 


232  CONSTIPATIOK".       HEADACHE.       INSOMNIA.        OBESITY. 

windows,  or,  if  possible,  in  the  outside  air  on  a  verandah,  both  winter  and 
summer. 

Room  exercises,  if  no  other  are  available,  are  invaluable,  especially 
those  which  strengthen  the  abdominal  muscles,  and  thus  aid  both  by  giving 
support  to  the  abdominal  viscera  and  by  relieving  venous  stasis  in  the  abdomen. 
For  example,  on  awaking  in  the  morning,  while -lying  flat  on  the  bed,  raising 
the  body  slowly  to  a  perpendicular  attitude  about  twenty  times  a  minute  with- 
out any  aid  from  the  arms;  or  raising  both  legs  to  a  perpendicular  position, 
while  the  body  remains  horizontal.  Kaising  one  leg  at  a  time  only  exercises 
the  psoas  and  iliacus  muscles,  but  raising  both  feet  brings  the  abdominal  mus- 
cles into  play.  Again,  standing  erect  and  bending  forward  with  stiff  legs, 
until  both  hands,  arms  extended,  are  brought  as  near  the  floor  as  possible,  and 
then  rising  slowly  again,  strengthens  the  back  muscles,  completing  the  circle 
of  the  body  cavity. 

The  physician  must  exercise  discretion,  however,  in  ordering  systematic 
exercises,  and  in  using  such  remedies  as  tend  to  stimulate  the  processes  of 
health  by  shocking  the  surface,  as  the  cold  bath ;  he  must  not  prescribe  a  nerve- 
exhausting  routine  of  this  sort  for  a  jaded  woman  with  no  latent  powers  of 
response.     To  do  this  is  as  wise  as  it  is  to  whip  a  fagged-out  horse. 

A  regular  system  of  hydrotherapy,  such  as  can  be  found  on  the 
Continent  of  Europe,  and  in  some  of  our  more  advanced  institutions,  is  often 
of  the  utmost  value. 

Associated  with  this  hygienic  regimen,  it  is  well  to  use  bitter  tonics. 
One  of  the  best  of  these  is  nux  vomica  in  increasing  doses,  beginning  with 
ten  drops  in  water  three  times  a  day,  and  increasing  the  amount  by  one  drop 
at  each  dose  until  the  patient  is  taking  twenty  to  twenty-five  drops  three  times 
daily.  If  there  is  any  twitching  of  the  muscles  or  stiffness  of  the  jaws,  the 
remedy  must  be  discontinued,  and  when  resumed,  the  dose  must  be  fixed  below 
the  amount  which  was  given  before.  Strychnin  often  works  admirably  and 
better  than  nux,  given  in  pilules,  containing  each  one-thirtieth  of  a  grain, 
increasing  the  dose  rapidly  until  one-tenth  of  a  grain  is  being  taken  three 
times  a  day. 

For  a  patient  who  has  headaches  often  and  is  below  par.  Dr.  I.  J.  Prouty 
often  gives : 

^   Ammon.  bromid gr.  v 

Tr.  nux  vomica TTL  x 

Elix.  simpl oj 

M.  S.  Take  in  water  after  meals ;  the  nux  should  be  increased  from 
time  to  time  until  t^-enty  to  twenty-five  drops  are  taken 
each  time. 

5.  Prevention  should  be  written  in  large  letters  and  hung  on  the  walls 
of  every  consulting  room,  and  prevention  and  hygienic  measures  walk 
well  hand  in  hand.     By  prevention  I  mean  such  a  careful  inquiry  into  the  gen- 


TREATMENT    OP    HEADACHE.  233 

eral  condition  and  the  habits  of  the  patient,  both  as  to  exercise,  hours  of  sleep, 
character  of  amusements,  reading,  and,  above  all,  diet,  as  shall  elucidate 
the  probable  causes  at  work  in  causing  the  headaches.  It  may  be,  especially  in 
thoughtless  young  persons,  that  late  hours,  and  unhealthy,  exciting  reading  are 
at  fault ;  it  may  be  that  the  day  is  all  spent  indoors,  ending  up  with  the  theatre 
or  a  hot  ballroom.  Most  frequently,  however,  the  fault  is  dietary ;  sometimes 
the  capricious  appetite  craves  only  highly  seasoned  food  and  pastry,  with  strong 
black  coffee  or  tea  several  times  a  day.  In  all  these  things  to  know  is  to  act, 
and  to  effect  a  cure,  a  word  to  the  wise  is  ever  sufficient. 

Where  the  suffering  arises  from  anemia  of  the  brain,  it  is  sufficient  to 
check  the  flow  of  blood  which  is  causing  it,  or  to  restore  the  normal  corpuscular 
balance  of  the  blood  to  cure  the  headache.  Iron  is  indicated  in  most  cases 
of  headache  accompanied  by  anemia  and  may  be  given  in  any  of  the  various 
preparations  already  discussed  (see  Chap.  VI,  p.  156).  In  some  instances, 
however,  the  pain  is  increased  by  iron,  and  it  is  best  to  substitute  arsenic 
(see  Chap.  YI,  p.  157)  or  cod-liver  oil.  I  have  found  that  the  use  of  a 
large  electric  light  (thirty-two  candle  power),  "thermal  electric  light,"  in  a 
parabolic  reflector,  applied  to  the  side  of  the  head  and  the  back  of  the  neck  is  of 
value,  but  possibly    suggestion   plays  a  more  or  less  important  role  here. 

6.  Remedies  which  act  upon  arterial  tension. — In  all  cases  with 
high  blood  pressure,  as  evidenced  by  the  full  bounding  pulse,  the  bromides 
of  soda,  of  potash,  andof  magnesia,  given  in  doses  of  ten  grains  or 
more,  in  one  to  two  teaspoonfuls  of  simple  elixir  every  hour  until  the  pain  is 
relieved,  are  of  the  utmost  service.  ISTitroglycerin  in  doses  of  one-hundredth 
of  a  grain  every  few  hours,  as  occasion  arises,  is  of  inestimable  value,  especially 
in  the  old,  whose  arteries  are  in  bad  condition.  But  the  best  of  all  remedies  in 
such  cases  is  the  nitrite  of  soda  in  half -grain  doses,  three  times  a  day,  con- 
tinued as  long  as  the  tension  remains  high;  it  is  particularly  valuable  where 
there  is  a  sort  of  status  of  headache.  Marked  disturbances  of  the  circulation 
are  sometimes  seen  after  serious  operations,  with  high  pressure  and  headache. 
The  sodium  nitrite  is  invaluable  here.  On  the  other  hand,  in  cases  of 
headache  where  the  arterial  tension  is  low,  ergotin  in  doses  of  one- 
fourth  of  a  grain,  increased  up  to  one  grain  if  necessary,  three  times  a  day,  is 
of  great  value. 

In  the  headaches  of  pregnancy,  the  bromides  are  most  useful, 
associated  with    diuretics    and    mild    purgatives. 

Y.  Remedies  which  remove  the  cause,  when  that  is  intra- 
cranial or  circulatory.— The  iodide  of  potash  in  syphilitic 
headache  is  the  great  specific  remedy  of  this  class.  ISTo  social  status  lies 
beyond  the  pale  of  this  disease,  and  the  drug  is  always  worth  trying  in  intense 
persisting  headache  with  visual  symptoms,  when  other  remedies  fail.  The  tol- 
erance of  the  drug  may  prove  to  be  the  only  diagnostic  factor  discoverable. 

Quinine  in  malarial  headache  is  similarly  valuable.  If  the  case  is 
a  frank  one,  the  remedy  may  be  tried  in  doses  of  five  to  ten  grains,  three  times 


234  cojSTSTipatiox,     headache,     insomnia,     obesity. 

a  day,  watching  its  effect  and  stopping  it,  if  there  is  any  buzzing  or  roaring  in 
the  ears.  Quinine  is  sometimes  of  value  in  headache  where  no  malarial  ele- 
ment  exists ;  in  such  cases  it  is  supposed  to  act  by  raising  blood  pressure. 

In  rheumatic  headache,  the  uric  acid  diathesis  which  underlies 
it  demands  a  course  of  ajDpropriate  treatment,  for  which  I  must  refer  to  the 
text-books  on  general  medicine.     Lauder  Brunton  recommends : 

3>    Pot.  bromidi gr.  xv 

Sod.  salicylat gr.  v 

M.     et  ft.  charta. 

Instead  of  the  salicylate,  aspirin  may  be  used  in  doses  of  six  to  seven 
grains,  repeated  every  two  to  three  hours,  during  an  attack. 

Trepanation,  excision  of  a  scar,  of  an  area  of  fracture,  or 
of  a  spiculated  bone  pressing  on  the  brain  is  a  brilliant  remedy,  but  one 
which  is  successful  in  too  small  a  percentage  of  cases,  even  where  the  indica- 
tions for  it  seem  to  exist,  to  justify  its  being  advised  with  assurance ;  a  well- 
defined  hope  is  all  that  can  be  held  out.  The  same  thing  may  be  said  in  regard 
to  the  removal  of  the  ganglion  of  the  fifth  nerve  for  intense 
one-sided  headache.  In  cases  of  this  kind  only  a  competent  neurologist 
can  decide  as  to  the  probability  of  relief  by  this  means. 

Remedies  which  act  through  a  mild  sedative  effect  or  by 
inducing  sleep  are  invaluable  when  the  pain  is  unbearable,  but,  unfortu- 
nately, though  brilliantly  successful  in  affording  relief,  they  do  nothing  to  effect 
a  cure.  First  among  these  is  the  sulphate  of  morphin,  given  hypoder- 
mically,  in  doses  of  a  quarter, of  a  grain,  or,  in  extreme  cases,  a  half.  The 
extract  of  cannabis  indica,  one-half  to  three-quarters  of  a  grain,  in  pill 
form,  is  often  of  great  value.  It  is  not  easy,  however,  to  obtain  a  reliable 
23reparation  of  this  drug;  if  a  good  article  is  foimd,  it  is  best,  as  H.  C.  Wood 
long  since  advised,  to  secure  all  of  it  and  use  that  alone.  It  must  always  be 
borne  in  mind  in  giving  cannabis  indica  that  some  individuals  have  a 
marked  susceptibility  to  it. 

The  bromides  and  chloral  belong  in  this  class  of  remedies,  but  the 
latter  is  a  dangerous  drug  for  the  patient  to  take  into  her  ovti  hands.  A  good 
prescription  for  the  bromides  is: 

19   Ammon.  brom ^J 

Elix.  simpl fojss. 

M.      S.   Take  a  tablespoonful  and  repeat  every  hour  until  relieved. 

In  more  severe  cases  a  substantial  dose  of  the  bromide  must  be  given  and 
chloral    added,  according  to  the  following,  or  some  similar  prescription: 

^   Sod.  brom 3ij 

Chloral  hydrat ^j 

Elix.   simpl f3jss- 

M.      S.   Take  a  tablespoonful  and  repeat  in  one  to  two  hours  if  necessary. 


TREATMENT  OF  HEADACHE.  235 

Hoffman's  anodyne  (compound  spirits  of  ether)  is  a  remedy  whicli 
has  often  rendered  good  service  in  the  past,  but  has  been  largely  abandoned, 
owing  to  the  difficulty  of  getting  a  really  good  preparation  containing  the 
heavy  oil  of  wine.  It  should  be  taken  in  teaspoonful  doses  in  a  wineglassful  of 
water. 

Last  in  this  group  of  remedies  I  mention  the  coal-tar  preparations, 
valuable  when  used  judiciously,  but  dangerous  in  careless  hands,  that  is,  in  the 
hands  of  the  patient  herself  or  of  the  quack  advertiser.  The  cases  now  and  then 
coming  to  light  before  coroners'  juries  are  but  a  small  index  of  the  numerous 
deaths  from  this  cause  to  be  laid  at  the  door  of  the  quacks.  In  some  cases  an 
idiosyncrasy  exists  which  makes  an  ordinary  dose  of  any  coal-tar  preparation 
dangerous ;  the  heart's  action  becomes  unduly  depressed,  a  fact  shown  by  blue- 
ness  of  the  lips  and  nails,  or  even  of  the  whole  circulation ;  the  cyanosis  may 
be  perceptible  to  others,  when  the  patient  herself  is  unaware  of  it.  There  is 
drowsiness,  amounting  in  severe  cases  to  coma,  and  if  the  drug  is  continued  for 
some  time,  it  induces  a  nephritis.  As  I  write,  I  hear  of  the  death  of  an  ac- 
quaintance who  had  taken  his  mistress  to  an  abortionist  in  ISTew  York  City.  He 
had  a  weak  heart  and  was  suffering  from  a  severe  headache.  The  abortion 
monger  gave  him  a  coal-tar  ready  relief  remedy,  and  in  one  hour  he  was  dead. 
This  is  but  one  among  hundreds  of  similar  cases.  Caution  spelled  in  large 
letters  is  the  warning  to  place  on  every  coal-tar  prescription. 

A  good  prescription  is : 

1^   Phenacetin  or  acetanilid    gr.  iij— v 

CafFein gr.  j 

Sod.  bicarb gr.  iij 

M.     et  ft.  ch.  1. 

S.       Take  as  directed. 

The  caffein  serves  to  balance  the  depressing  effect  of  the  acetanilid. 
Some  physicians  prescribe  a  dose  of  whiskey  with  each  dose  of  acetanilid, 
but  the  evils  of  alcohol  are  so  great  that  I  prefer  using  aromatic  spirits  of 
ammonia  in  twenty  to  thirty  drop  doses  in  a  little  water.  The  aromatic  spirits 
alone  in  water  is  an  excellent  remedy  where  the  stomach  is  somewhat  disturbed. 
In  using  coal-tar  preparations  there  always  lurks  the  danger  of  forming  a  habit 
which  in  the  end  endangers  life  by  its  effects  upon  the  heart. 

Migraine  or  Sick  Headache. — I  will  now  devote  a  little  time  to  the  considera- 
tion of  sick  headache  and  its  management.  In  sick  headache,  prodromic 
symptoms  are  often  present;  of  which  the  most  constant  is  the  sensation  of  a 
blinding  light.  Some  patients  display  marked  psychical  disturbances, 
either  of  excitement  or  of  depression.  Dizziness  and  giddiness  are  not 
uncommon  precursors;  and  in  the  gouty  or  rheumatic  form,  the  head- 
ache is  often  preceded  by  stiffness  or  shooting  pains  in  the  joints. 

The  headache  at  first  is  often  situated  on  one  side  of  the  head ;  in  some  cases 
it  always  starts  on  the  same  side,  Avhile  in  others  it  alternates.     It  generally 


236  CONSTIPATION.        HEADACHE,       INSOMNIA.       OBESITY. 

begins  in  one  spot  near  the  temple,  and  extends  downwards  along  the  affected 
side,  sometimes  following,  roughly  speaking,  the  course  of  the  fifth  nerve  and 
extending  to  the  shoulder  and  arm.  Shortly  after  the  onset  of  the  headache, 
one  of  the  chief  symptoms,  nausea,  appears,  and,  as  a  rule,  increases  until 
it  ends  in  violent  vomiting  and  retching,  when  at  first  the  contents  of  the 
stomach  are  ejected  and  later  bile.  In  severe  attacks,  when  the  retching  con- 
tinues long  after  the  stomach  is  emptied,  it  greatly  exhausts  the  patient.  Vaso- 
motor disturbances  are  also  a  marked  feature  of  sick  headache,  the  face 
being  at  times  deadly  pale,  and  at  other  times  a  burning  red.  When  the  pain 
is  confined  to  one  side,  the  vaso-motor  disturbance  is  similarly  restricted.  One 
peculiar  feature  attending  some  sick  headaches  is  an  overpowering  sense  of 
drowsiness,  sometimes  so  irresistible  as  to  overcome  even  the  severity  of  the 
pain  and  induce  heavy  sleep  in  the  intervals  of  vomiting.  Sick  headaches  in 
women  have  a  marked  tendency  to  appear  at  the  menstrual  periods, 
either  before,  during,  or  after  menstruation.  The  duration  of  the  sick  head- 
ache is  usually  from  twelve  to  twenty-four  hours ;  they  generally  leave  the 
patient  utterly  exhausted.  Young  women,  with  strong  recuperative  powers, 
recover  quickly,  but  older  persons  are  often  incapacitated  for  several  days.  As 
life  advances,  however,  the  headaches  usually  show  a  tendency  to  decrease  in 
violence,  although  there  is  likely  to  be  a  period  of  great  severity  about  the  time 
of  the  menopause.  After  menstruation  has  ceased,  they  occur,  as  a  rule,  much 
more  rarely. 

Treatment. — In  sick  headache  it  is  useless  to  give  remedies  by  the  mouth 
during  the  violence  of  the  attack,  for  the  stomach  will  not  retain  them.  A 
hypodermic  of  morphin  is  practically  the  only  drug  which  can  give  any 
relief,  but  it  is  only  in  cases  of  extreme  suffering  or  occasions  of  special  urgency 
that  the  physician  is  justified  in  resorting  to  this  measure.  Under  no  circum- 
stances must  he  allow  the  patient  to  use  the  hypodermic  syringe  herself,  for  the 
recurrent  nature  of  the  disorder  peculiarly  favors  the  formation  of  a  drug  habit. 
Occasionally,  a  strong  mustard  plaster  over  the  upper  cervical  region 
gives  some  relief,  but,  as  a  rule,  when  a  headache  of  this  kind  has  once  begun, 
the  only  thing  to  be  done  for  the  patient  is  to  keep  her  absolutely  quiet  in  a 
darkened  room,  until  the  violence  of  the  attack  has  subsided. 

A  great  deal  can  be  done  for  the  relief  of  such  headaches,  however,  by 
prophylaxis.  Persons  subject  to  them  are  well  aware  that  the  attacks  are  most 
frequent  if  their  general  health  is  depreciated,  or  if  they  are  exposed  to 
unusual  excitement  or  fatigue.  TVhen  it  can  be  established  that  they  are  asso- 
ciated with  a  gouty  or  rheumatic  constitution,  the  underlying  condi- 
tion should  be  treated.  Constipation  should  be  especially  guarded  against, 
for  in  many  cases  the  permanent  relief  of  a  constipated  habit  has  been  followed 
by  permanent  relief  of  the  headaches.  Xot  infrequently  a  torpid  liver  exists 
in  such  cases,  and  the  administration  of  a  small  dose  of  calomel  at  inter- 
vals of  al)nnt  ten  days  for  a  period  of  several  months  Avill  do  nuich  towards 
relief.     A  lu'okcn  dose  of  one-half  to  one  grain  in  powders,  or  tablets  of  one- 


TREATMENT    OF    MIGRAINE.  237 

eigl;ith  of  a  grain,  at  intervals  of  half  an  hour,  followed  next  morning  by  a  saline 
pnrge,  is  the  best  form  of  administration.  A  wholesome  varied  diet, 
plenty  of  fresh  air  and  exercise,  attention  to  the  bowels,  and 
avoidance  of  over-fatigue  and  excitement  will  do  a  great  deal 
towards  reducing  the  frequency  of  these  headaches.  The  physician  must  always 
bear  in  mind  the  fact  that  headaches  of  this  description  are  sometimes  due  to 
uremic  poisoning,  and  he  should  never  be  satisfied  to  treat  a  case  without 
assuring  himself  positively  as  to  the  presence  or  absence  of  nephritis. 


238  CONSTIPATION.        HEADACHE.       INSOMNIA.        OBESITY. 


INSOMNU. 

I  do  not  know  whether  an  nnusiially  large  percentage  of  patients  with  in- 
somnia calls  for  relief  at  the  consulting  rooms  of  the  gynecologist,  or  whether 
the  world  at  large  is  becoming  more  and  more  afflicted  with  this  disorder,  but 
of  one  thing  I  am  sure,  that  sleeplessness  is  a  distressingly  common  ailment. 
With  the  exception  of  the  neurologist,  it  probably  falls  to  the  lot  of  the  gyn- 
ecologist to  see  more  insomnia  than  any  other  specialist.  It  behooves  him, 
therefore,  not  only  to  pay  close  attention  to  those  cases  which  fall  peculiarly 
under  his  sphere,  but,  in  order  that  he  may  intelligeutly  select  his  cases,  to 
have  some  clear  knowledge  of  the  causes  and  treatment  of  insomnia  in  general. 
For  this  reason  I  give  here  the  conclusions  drawn  from  my  personal  experi- 
ences in  this  common  and  most  trying  malady. 

Etiology. — The  causes  of  insomnia  are  not,  as  a  rule,  recondite ;  they  lie  in 
the  mode  of  life,  in  upbringing,  in  occupation,  in  domestic  arrangements.  Let 
us  review  a  few  of  them.  In  the  first  place,  sleeplessness  is  peculiarly  common 
among  neurasthenics,  and  whatever  produces  neurasthenia,  con- 
spires to  produce  insomnia.  Some  neurasthenics,  especially  women,  are 
such  because  of  a  fundamental  defect  in  the  nervous  system ;  others  again  are 
acquired  neurasthenics  through  over-exertion.  The  recognition  of  these  two 
classes  has  an  important  bearing  on  the  prognosis  in  insomnia. 

Constant  over-taxation  in  attending  to  life's  duties  without 
relaxation  produces  first,  a  sense  of  weariness  which,  as  a  rule,  is  neglected; 
the  next  symptom  is  apt  to  be  an  insomnia  which  cannot  be  so  easily  overlooked, 
as  it  soon  begins  to  interfere  seriously  with  the  daily  activities  of  life.  Con- 
stant, fixed,  strained  attention  to  any  pursuit  produces  a  fulness  in 
the  head  which  leads  to  sleeplessness.  Continued  excitement,  vexation, 
or  a   great   sorrow   brings  about  the  same  result. 

It  must  also  be  remembered  that  a  persistent  insomnia  is  sometimes  the 
prodrome  of  grave  nervous  disorders.  In  children,  excessive 
study  produces  insomnia.  Some  patients  date  their  insomnia  from  habits  be- 
gotten in  childhood,  practices  due  to  a  lack  of  proper  parental  control,  relative 
to  proper  hours  of  going  to  bed. 

It  is  always  important  to  inquire  as  to  heredity,  as  sleeplessness,  in  a 
large  percentage  of  cases,  is  inherited  from  a  maternal  or  paternal  ancestor. 

These  and  kindred  causes  seem  to  show  that  insomnia  is  kept  up  by  a  loss 
of  vaso-motor  control,  or  a  vaso-motor  exhaustion,  resulting 
in    dilatation    of   the    capillaries. 

The  habit  of  turning  night  into  day,  or  as  one  of  my  associates 
puts  it,  "  the  habit  of  pottering  around  at  night,"  begetting  later  and  later 
hours,  tends  to  produce  a  wakefulness  which  is  hard  to  overcome.  One  of  my 
friends  who  acquired  an  insomnia  in  this  way,  found  that  a  small  dose  of 


TREATMENT    OF    INSOMNIA.  239 

whiskey  would  give  the  much  needed  rest ;  but  the  drug  soon  overmastered  the 
patient,  who  died  a  confirmed  drunlvard.  Coffee  and  tea  arc  responsible  for 
the  wakefulness  of  some  patients. 

There  are  diflferent  forms  of  insomnia,  namely,  the  early  night,  the 
early  morning,  and  the  all  night  forms.  In  other,  distressing  cases, 
there  is  fitful  sleep  or  half  sleep,  when  it  seems  to  the  patient  that  she 
has  really  been  awake  all  night.  Some  people  think  they  do  not  sleep,  when  in 
reality  they  get  a  number  of  hours  of  good  rest.  A  night  nurse  slipping  into 
the  room  at  intervals  through  the  night  will  often  correct  a  false  impression  of 
this  kind ;  but  it  is  not  always  well  to  tell  the  patient  that  she  has  had  a  good 
night's  rest,  as  she  may  resent  it. 

Treatment. — For  practical  purposes  cases  of  insomnia  may  be  grouped,  I 
think,  under  three  heads,  namely : 

1.  Cases  complicated  with  some  other  ailment,  in  which  there 
is  a  reasonable  hope  that  upon  removal  of  the  complication,  the  insomnia  will 
disappear. 

2.  Cases  in  which  the  insomnia  is  associated  with  symptoms 
of   a   pronounced   nervous   disorder,    and  is  of  a  more  extreme  form. 

3.  Simple,  mild  insomnia,  which  may  be  looked  upon  as  a  transient 
disorder,  perhaps  associated  with  some  minor  ailments  in  the  genital  tract,  or 
in  the  nervous  system. 

Cases  of  the  first  and  last  groups  come  continually,  and  come  appropriately 
to  the  gynecologist  for  relief.  The  distinction  between  either  of  these  and  cases 
of  the  second  group,  however,  is  sometimes  difficult  to  make,  as  no  hard  and 
fast  line  can  be  drawn  between  cases  which  are  closely  linked  to  the  mild 
neurasthenics  on  the  one  hand,  or  are  inseparably  connected  with  a  mild  pelvic 
disorder  on  the  other.  Sometimes  the  test  of  two  or  three  weeks'  observation 
alone  will  tell.  In  all  doubtful  cases,  a  neurologist  ought  to  be  called  in  to 
assist  in  the  decision.  Bad,  inveterate,  and  malignant  neurasthenics  do  not 
belong  by  rights  in  the  gynecologist's  hands  at  all. 

The  remedies  I  have  found  useful  and  applicable  in  the  milder  and  inter- 
current cases,  dissociated  from  any  profound  affection  of  the  nervous  system, 
may  be  grouped  as  follows : 

1.  Removal  of  the  cause. 

2.  Hygienic  remedies. 

3.  Drugs. 

1.  First  and  foremost  it  is  necessary  to  remove  any  evident 
cause  for  the  insomnia.  A  direct  cause,  as,  perhaps,  some  gross  lesion 
in  the  pelvis,  or,  it  may  be,  some  hidden  cause,  acting  alone  or  with  some  minor 
pelvic  lesion,  will  conspire  to  upset  the  nerve  balance  and  bring  .about  persistent 
sleeplessness.  A  local  affection,  such  as  a  relaxed  vaginal  outlet,  letting 
the  uterus  down  and  permitting  the  pelvic  structures  to  drag  on  their  attach- 
ments, will  produce  nervous  exhaustion,  as  well  as  a    nagging    displaced 


240  CONSTIPATION.        HEADACHE.       INSOMNIA.       OBESITY. 

kidne}'.  I  would  then  proceed  at  once  to  correct  these  troubles,  and  would 
expect  the  general  care,  the  feeding,  the  massage,  the  fresh  air,  and  the  sunshine 
baths,  that  ought  to  follow  an  operation,  to  relieve  the  insomnia  too.  Do  not 
let  the  patient  be  impatient  about  it,  however,  for  the  relief  may  be  more  positive 
after  she  is  up  on  her  feet  again  and  able  to  walk  out  naturally,  taking  health- 
ful exercise  without  the  previous  drag.  She  wall  then  grow  normally  tired  and 
sleep  normally  afterward. 

The  first  thing  then  is  to  operate  soon,  if  the  patient  needs  it, 
and  to  work  on  the  insomnia  while  the  other  reparative  processes  are  going  on, 
so  as  to  cure  the  sleeplessness,  if  possible,  pari  passu  with  the  healing  of  the 
wound. 

2.  Hygienic  Means  of  Relieving  Insomnia. — These  are  by  far  the 
most  important,  indeed  they  are  the  sheet  anchor  of  all  successful  treatment. 
Hygiene  is  the  purpose  of  all  forms  of  treatment,  whatever  they  may  be. 
However  they  may  begin,  in  hygiene  they  must  end,  in  order  to  be  successful 
and  self-perpetuating.  The  patient  who  is  better  while  in  the  hospital  after 
an  operation  must  be  committed  with  sedulous  care  to  mother  Hygeia  on  leav- 
ing. It  is  not  enough  for  the  physician  to  be  able  to  claim  that  the  wound 
healed  well  and  the  patient  slept  while  she  was  under  his  care. 

The  hygienic  means  at  our  disposal  are  these : 

A  good  bed. 

A  cool  room. 

A  proper  hour  for  going  to  bed. 

RegTilation  of  the  diet. 

Cold  and  hot  baths. 

Spinal  douches. 

Cold  packs. 

Massage. 

Electricity. 

Empty  bowels. 

It  is  not  my  proper  role  to  go  minutely  into  these  measures  which  are  more 
fully  described  in  works  on  hygiene  and  general  treatment. 

Some  patients  sleep  much  better  on  a  particular  kind  of  a  bed,  one 
on  a  hard  bed,  another  on  a  soft  cushiony  one;  and  when  this  is  the  case,  the 
bed  should  be  provided  without  thought  of  economy. 

A  cool  room,  temperature  sixty  degTees  Fahrenheit  or  lower,  is  conducive 
to  rest;  and  when  it  can  be  arranged,  it  is  a  good  plan  to  have  the  bed,  duly 
sheltered,  out  of  doors.  It  is  a  mistake,  however,  to  get  into  a  cold  bed  and  to 
be  kept  awake  by  cold  feet.  The  bed  ought  to  be  well  warmed  in 
winter,  and  if  the  patient  cannot  sleep  well  between  linen  or  cotton  sheets, 
soft  blankets  may  be  tried.  Before  going  to  bed,  a  hot  bath  (110°  E.) 
may  serve  to  draw  the  blood  to  the  skin  away  from  the  head  and  so  give  an 
impetus  to  sleep  at  the  outset.     Whenever  anything  is  done  to  promote  sleep 


TREATMENT    OE    INSOMNIA.  241 

before  retiring,  it  is  important  to  see  that  nothing  stimulates  thought  or  turns 
the  attention  actively  in  another  direction,  after  the  preventive  measure  is 
taken. 

I  shall  not  say  more  about  the  diet  than  to  indicate  that  a  simple  nu- 
tritious food  is  best.  Late  suppers  and  such  nerve  excitants  as  alcoholic 
beverages,  tea,  or  coffee  should  be  avoided.  It  is  often  of  benefit,  however,  to 
give  the  patient  a  cup  of  gruel  or  hot  malted  milk  on  retiring,  say  about  two 
hours,  after  a  moderate  supper.  The  fermentation  in  the  stomach  imposed  by  a 
heavy  dinner  keeps  many  persons  restless  and  awake;  this  must  always  be 
looked  into. 

Whatever  mav  be  the  difficulty  in  sleeping,  the  patient  must  go  to  bed 
at   a   reasonable   hour,    say  ten  o'clock  or  earlier,  and  not  later  than  eleven. 

Patients  who  wake  up  in  the  night  are  often  helped  by  taking  some  food ;  a 
glass  of  milk  is  the  simplest,  for  it  can  stand  close  to  the  bedside  ready  for  use. 

When  the  patient  takes  a  holiday  cure,  there  is  nothing  like  the  activities 
of  a  simple  camp  life  and  a  good  rubber  air  bed  in  the  woods  to  promote 
sound  refreshing  sleep. 

The  bowels  must  be  kept  emptied  regularly,  as  a  copremia  is 
often  the  cause  of  wakefulness.  Massage  is  a  gTeat  help  for  a  time,  but  it  is 
only  a  temporary  expedient,  for  the  most  part  for  the  bedridden,  as  the  patient 
must  soon  be  thrown  on  her  own  resources  to  find  natural  healthful  exercise 
day  by  day. 

General  electricity  works  in  a  manner  analogous  to  massage  and  is  a 
good  alternant  with  it.  Sometimes  an  early  night  wakefulness  is  relieved  by 
the  application  of  electricity  and  a  gentle  massaging  of  the  scalp. 

Of  all  the  remedies  for  sleeplessness  at  our  command  the  cold  pack  is, 
perhaps,  the  most  generally  useful.  It  is  given  in  this  way:  The  patient  is 
placed  upon  a  rubber  sheet  with  a  woolen  blanket  on  top  of  it.  Her  nightdress 
is  then  taken  off  while  she  is  kept  well  covered  with  a  blanket,  and  she  is  then 
turned  upon  her  side.  A  sheet  is  wrung  out  of  water  at  the  temperature  or- 
dered, which  may  be  anywhere  from  100°  F.  to  the  temperature  at  which  it 
runs  from  the  spigot.  The  sheet  must  be  so  folded  that  the  thin  edge  will  be 
at  the  outside  of  the  bed.  The  patient  is  then  rolled  in  the  sheet  so  that  she  is 
entirely  enveloped  in  it,  after  which  the  edges  of  the  blanket  are  brought  be- 
neath her,  each  layer  tucked  in  carefully,  and  the  rubber  blanket  finally  brought 
over  the  whole  so  that  her  entire  body  is  covered  by  it.  A  hot-water  bag  must 
be  placed  at  the  patient's  feet.  If  she  does  not  warm  up  promptly,  additional 
blankets  may  be  used.  She  should  remain  in  the  pack  for  from  five  to  twenty 
minutes,  and  when  taken  out,  she  must  be  carefully  rolled  in  a  dry  blanket 
and  briskly  rubbed  with  a  Turkish  towel,  after  which  her  nightdress  is  replaced 
and  she  is  put  between  sheets  again. 

Our  best  neurologists  to-day  are  making  large  use  of  hypnotism  and 
suggestion  in  inducing  sleep.  To  effect  anything  by  this  means,  the  physi- 
cian must  know  his  patient  well  enough  to  inspire  confidence  and  must  engage 
17 


242  COXSTIPATIOX.        HEADACHE.       IXSOIMXIA.        OBESITY. 

lier  aid  iu  a  coiiiiuun  cau^e,  operating'  against  a  cuumjuu  enemy,  insomnia.  The 
attitude  of  expectation  thus  created  must  be  enhanced  by  the  external  conditions 
of  the  moment,  such  as  retiring  at  a  fixed  hour,  quieting  the  mind,  and  com- 
posedly awaiting  the  advent  of  the  expected  guest,  sleep. 

The  worst  cases  of  insomnia  must  be  treated,  like  bad  neurasthenics,  by 
absolute  isolation  and  rest  in  bed  for  several  weeks  or  longer,  under  the  charge 
of  one  nurse,  the  patient  not  even  being  allowed  to  hear  from  a  relative  or  read 
a  letter,  much  less  receive  visitors. 

What  shall  I  say  about  the  treatment  of  that  most  distressing  of  all  forms 
of  wakefulness  which  springs  from  a  mental  distress,  when  the  poor  victim,  un- 
able, as  in  the  daytime,  to  escape  from  her  anxiety  in  many  hourly  distractions, 
lies,  and  thinks,  and  tosses,  and  readjusts  her  circumstances,  dwelling,  perhaps, 
on  some  critical  event,  in  which,  if  she  had  acted  differently,  her  distress  would 
have  been  spared.  The  true  physician  will  not  play  the  coward  here,  but  will 
esteem  it  his  highest  privilege,  according  as  he  has  grace  given  him  to  inter- 
vene, to  heal  the  moral  or  the  family  ill,  as  well  as  the  physical,  and  so  to  put 
the  wearied  mind  at  rest.  This  is  the  truly  difficult  side  of  our  labors,  far  more 
difficult  than  any  mere  laboratory  analysis,  and  for  this  reason  many  men,  even 
among  those  who  are  accounted  great,  run  away  from  it  incontinently. 

Drugs. — I  now  come  to  the  drug  treatment  of  insomnia,  much  decried, 
but  everywhere  used,  and  in  most  cases  necessary  for  a  limited  time. 

The  drug  is  a  crutch  for  the  cripple  on  the  road  to  the  house  of  Hygeia,  and 
sometimes  the  cripple  cannot  get  there  without  it ;  or  she  gets  there  much 
faster  for  the  temporary,  judicious,  carefully  supervised  aid  of 
the   crutch. 

My  list  of  drugs  is  but  a  short  one:  Trional,  aspirin,  veronal, 
codein,  sulphonal,  bromide  of  potash,  chloral.  The  ideal  hypnotic 
has  not,  and  it  is  safe  to  say,  never  will  be.  found ;  in  fact  it  would  be  a  mis- 
fortune if  one  were  ever  discovered,  as  it  would  then  be  used  universally  and 
persistently,  to  the  exclusion  of  the  return  to  natural  sleep  by  the  gateway  of 
hygienic  methods. 

It  will  be  seen  upon  examining  the  different  drugs  on  the  list  that  there 
is  not  one  which  can  be  kept  up  indefinitely.  "  For  temporary  use  "  ought  to 
be  written  on  the  label  of  the  vial  containing  any  one  of  them.  Prescriptions 
for  them  ought  not  to  be  re-filled  except  by  order  of  the  physician,  because 
of  the  extreme  danger  of  forming  the  drug  habit,  as  well  as  that  arising  from 
the  pathological  effects  they  may  have  upon  the  kidneys  or  the  circulatory 
system. 

Aspirin,  in  five  to  ten  grain  doses,  is  of  use  where  the  insomnia  is  asso- 
ciated with  headache.  For  wakefulness  which  occurs  as  soon  as  the  patient 
goes  to  bed,  trional,  in  doses  of  five  to  ten  gTains,  is  one  of  the  best  remedies 
we  have;  for  wakefulness  in  the  latter  part  of  the  night,  sulphonal  in  doses 
of  ten  grains  is  better.  I  have  known  the  combination  of  the  two  to  work 
beautifully. 


TEEATMENT    OF    INSOMNIA.  243 

^   Trional gi\  v 

Siilphonal gr.  vii 

M.  et  ft.  charta. 
S.    Take  at  bedtime. 

It  must  always  be  remembered  that  siilphonal  is  occasionally  extremely  in- 
jurious to  the  kidneys,  especially  if  given  for  a  long  time. 

There  is  a  certain  class  of  patients  who  go  to  sleep  easily,  but  cannot  stay 
asleep.  With  them  it  is  a  good  plan  to  give  ten  grains  of  siilphonal  about  four 
o'clock  in  the  afternoon  and  ten  grains  of  trional  at  bedtime.  Trional,  in  some 
cases,  is  more  effective  if  given  in  a  suppository  containing  fifteen  grains. 

Another  excellent  remedy  is  veronal.  Five  to  ten  grains  is  the  usual  dose, 
though  as  much  as  fifteen  grains  may  be  given.  Veronal  must  be  watched 
and  stopped  if  it  produces  any  unpleasant  symptoms.  The  bromideof 
sodium  or  of  potassium  in  combination  with  veronal  gives  excellent 
results. 

I^   Potass,  bromid oiij 

Veronal gr.  xlviii 

Elix.  simpl foiij 

M.     S.   Tablespoonful  at  bedtime. 

This  combination  will  give  a  nervous,  overAvroiight,  excited  patient  a  good 
night's  rest  when  everything  else  fails.  It  must  always  be  given  in  solution, 
never  in  powder  form,  as  it  has  a  tendency  to  irritate  the  stomach. 

In  a  bad  case  of  insomnia,  a  combination  of  bromide  and  chloral  may  be 
used  for  one  or  two  nights. 

I^   Potass,  bromid gr.  xl 

Chloral  hydrat gr.  xx 

Elix.  simpl f §ss. 

M.     S.  Take  at  bedtime. 

Hyoscin  hydrobromate,  given  hypodermically  in  a  dose  of  one-hun- 
dredth to  one-sixtieth  of  a  grain,  is  of  value  in  extremely  nervous  cases  bor- 
dering on  insanity. 


244  CONSTIPATION.        HEADACHE.       INSOMNIA.       OBESITY. 


OBESITY. 

It  is  not  niY  intention  to  do  more  here  than  refer  to  obesity  in  general  and 
to  give  briefly  in  ontline  such  simple  facts  as  ought  to  be  in  the  possession  of 
the  practitioner  who  undertakes  to  treat  any  form  of  it. 

Obesity,  corpulence,  or  an  excessive  deposit  of  adipose  tis- 
sue in  the  body  is  a  common  affection  among  women,  sometimes  in  association 
with  disorders  of  the  pelvic  organs,  and  so  characteristic  of  married  women 
advancing  beyond  middle  life  that  it  almost  constitutes  the  typical  character- 
istic of  the  sex  at  this  period.  The  fat,  as  a  rule,  is  uniformly  deposited  in 
all  situations  where  it  is  normally  present,  namely,  about  the  face,  the  shoulders 
and  arms,  the  chest,  the  abdominal  walls,  within  the  abdomen,  and  over  the 
thighs  and  legs.  When  the  superincumbent  fat  finds  no  support  below,  it  falls 
downwards  in  transverse  folds,  creating  a  double  chin,  wattles  on  the  back,  or 
great  folds  across  the  lower  abdomen,  hanging  over  the  symphysis.  In  such 
patients  the  specific  gTavity  of  the  blood  is  usually  increased  and,  as  a  rule,  the 
percentage  of  hemoglobin,  creating  a  plethora.  The  most  serious  complication, 
however,  is  extensive  dej)osits  of  fat  about  the  heart  and  in  the  intermuscular 
interstices,  by  which  the  organ  itself  is  literally  smothered ;  even  the  coats  of 
the  arteries  are  sometimes  affected. 

Etiology. — Heredity  is  a  strong  predisposing  cause  in  obesity  and  is  some- 
times the  only  one  which  can  be  assigTied.  Anders  ("  Practice  of  Medicine," 
1900,  p.  1226)  noted  that  out  of  two  hundred  and  two  cases  of  obesity  in  his 
practice  heredity  was  distinctly  traceable  in  sixty  per  cent ;  in  fourteen  cases 
out  of  the  number  it  had  existed  from  childhood.  Gout  and  rheumatism 
are  factors  in  a  good  many  cases.  Fibroid  tumors  are  often  accompanied  by 
an  increase  in  weight,  while  ovarian  troubles  are  associated  with  a  tendency 
to  emaciation.  In  some  cases  of  anemia  or  chlorosis  the  patient  gains 
flesh  from  the  non-oxidation  of  food. 

Amenorrhea  is  often  accompanied  by  obesity  and  under  these  circum- 
stances the  gain  in  flesh  is  often  extremely  rapid,  it  may  be  as  much  as  fifty 
or  sixty  pounds  in  the  course  of  a  few  months  (see  Chap.  VI).  The  estab- 
lishment of  the  menopause,  as  is  well  known,  is  accompanied,  in  the 
majority  of  cases,  by  an  increase  in  weight,  and  the  same  thing  is  observed  to 
follow  the  removal  of  the  ovaries  before  their  functional  activity  is  com- 
plete. Exactly  what  governs  the  increase  of  adipose  tissue  in  the  three  latter 
classes  of  cases  is  not  known;  the  most  we  can  say  is  that  with  the  disappear- 
ance of  the  ovarian  function  and  the  glandular  corpora  lutea  the  tendency  to 
take  on  flesh,  which  has  up  to  that  time  been  held  in  abeyance,  gains  the  upper 
hand;  this  is  especially  apparent  in  the  Jewish  race. 

Symptoms. — The  symptoms  of  excessive  adipose  tissue  (polysarcia)  are:  in- 
disposition  to   engage   in   active  pursuits,    or  even  to  walk  or  take  the 


TREATMENT    OF    OBESITY.  245 

most  moderate  exertion;  breathlessness  on  moderate  exertion; 
plethora,  as  shown  by  the  frequent  flushing  of  the  face,  increased  by  exertion 
and  often  ending  in  dizziness.  In  young  women,  the  rapid  taking  on  of  fat  is 
marked,  as  a  rule,  by  the  lessening  of  the  menstrual  flow,  which  may 
even  cease  altogether  for  months  or  years — this  form  of  amenorrhea  is  com- 
monly associated  with  sterility. 

Treatment. — The  first  stej)  to  be  taken  in  the  treatment  of  obesity  is  to  ascer- 
tain the  cause  and,  if  possible,  remove  it.  If  the  patient  gives  a  history  of 
gout  she  must  be  put  upon  a  proper  regimen  for  it.  In  anemia  and 
chlorosis  the  administration  of  iron,  arsenic,  and  cod-liver  oil  is 
often  accompanied  by  a  decrease  in  weight  instead  of  a  gain,  as  in  other  affec- 
tions, for  example,  tuberculosis.  The  obesity  associated  with  amenorrhea  is 
dependent  upon  the  underlying  condition  which  occasions  the  suppression  of 
menstruation,  and,  as  a  rule,  can  only  be  successfully  dealt  with  through  it. 
In  such  cases  I  always  try  lutein  tablets,  five  grains  each,  made  from 
the  dried  corpora  lutea  of  swine,  given  three  times  a  day.  In  some  cases  they 
are  followed  by  excellent  results. 

In  the  obesity  of  women  approaching  or  past  the  menopause  the  following 
lines  of  treatment  are  of  value:  When  the  patient  is  a  large  eater  the  amount 
of  food  must  be  cut  down  ;  and  with  the  lessened  ingestion  of  food  the 
patient  will  do  well  to  spend  more  time  in  the  thorough  mastication  or 
"  insalivation  "  of  what  she  takes.  Most  women  over  forty  take  more  food 
habitually  than  is  at  all  necessary  at  a  period  of  life  when  the  activities  of 
growth  and  of  child-bearing  are  at  an  end.  Unfortunately,  those  women  who 
consult  the  gynecologist  on  account  of  excessive  fat  are  generally  troubled  with 
the  affection  in  its  less  distressing  forms,  and  they  are,  as  a  rule,  unwilling  to 
take  any  trouble  or  practice  any  self-denial  to  lessen  their  weight,  least  of  all 
to  modify  their  habits  of  life.  If,  however,  the  patient  is  disposed  to  take  her 
condition  seriously  and  to  regulate  her  life  each  day  so  as  to  reduce  her  weight, 
a  regular  course  of  treatment  should  be  prescribed,  during  which  she  must  be 
under  medical  supervision  both  as  to  the  effect  as  tested  by  the  scales  and  as 
regards  her  general  health.  Before  prescribing  such  a  course  of  treatment  the 
physician  should  make  out  an  outline  of  the  patient's  history  and  of  the  line  of 
treatment  proposed.     I  give  the  following  outline  as  a  suggestion: 

ISTame. 

Age. 

^N^umber  of  children,  if  married. 

Menstruation,  as  regards  regularity  and  amount. 

Menopause. 

Present  weight. 

Increase  in  weight  over  usual  amount. 

Rapidity  of  increase. 

Symptoms  associated  with  increase  in  weight. 


2-16  CONSTIPATION.        HEADACHE.       IXSOMXIA.        OBESITY. 

Food,  amount,  character,  regularity  of  meals,  amount  eaten  between 
regular  meals.  Write  out  a  description  of  average  meals,  break- 
fast, dinner,  supper  or  lunch. 

Water,  amount  taken. 

Alcoholic  beverages. 

^Vniount  of  exercise  taken  and  nature. 

Any  mental  peculiarities,  especially  sluggishness  suggesting  myxe- 
dema. 

With  these  data  before  him  as  a  working  basis,  the  physician  should  under- 
line the  prominent  factors  in  the  case,  such  as  menopause  ;  amenorrhea; 
increase  in  weight  within  three  years;  much  fat  and  starch  in 
ordinary  diet:  excessive  amount  of  water  taken;  exercise  only 
about  the  house. 

The  physician  must  then  proceed  to  treat  each  case  according  to  ideas  sug- 
gested by  prominent  facts  brought  out  in  this  investigation.  The  following 
general  principles  are  always  to  be  borne  in  mind : 

It  is  necessary  to  promote  the  oxidation  of  fat  in  the  system 
and  prevent  the  ingestion  of  new  supplies  ;  in  order  to  accomplish 
this  the  amount  of  fat-forming  foods  must  be  limited,  while  the  amount  of 
exercise  and  other  factors  increasing  fat  destruction  must  be  increased.  In 
the  first  place  it  is  well  to  diminish  the  total  quantity  of  food.  The  average 
diet  for  an  adult  is  one  hundred  and  twenty-five  grammes  of  albumen,  eighty 
of  fat,  and  three  hundred  and  fifty  of  starch.  In  attempting  the  reduction 
of  obesity  the  albuminoids  must  be  diminished  least  and  the  fats  and  starches 
to  a  much  greater  degree.  Most  cases  of  obesity  would  improve  on  one  hundred 
and  twenty-five  gTammes,  or  more,  of  albumen,  forty  of  fat,  and  one  hundred 
and  fifty,  or  even  less,  of  starch.  It  is  wisest,  however,  to  reach  this  amomit  of 
reduction  by  degrees.  In  the  later  stages  of  the  treatment,  when  considerable 
amoimts  of  tissue  have  been  lost,  the  non-nitrogenous  foods  should  be  increased, 
so  that  the  albuminous  tissues  of  the  body  do  not  become  wasted.  The  treat- 
ment must  be  kept  up  for  weeks  or  months  as  the  case  requires,  and  the  cure 
must  not  be  considered  complete  until  the  weight  is  brought  down  to  what  is 
normal  for  age,  size,  and  sex.  A  rapid  loss  of  weight  at  the  beginning  of  the 
treatment  is  not  desirable ;  two  to  three  pounds  a  week  is  much  better  for  the 
patient  than  a  larger  amount. 

If  any  benefit  is  to  be  derived  from  the  treatment,  the  physician  must 
insist  upon  its  being  conscientiously  carried  out  and  the  patient  must  be 
willing  to  comply  Avith  the  directions.  Where  compliance  with  directions  is 
difficult  or  impossible  at  home,  it  is  an  excellent  plan  to  send  her  to  some 
Spa,  such  as  Carlsbad,  Marienbad.  or  in  this  country,  to  the  Hot  Springs  of 
Virginia. 

The  following  diet  list  for  olesity  is  taken  from  Friedenwald  and  Rurah 
("  Diet  in  Health  and  Disease,"  1905)  : 


TREATMENT    OF    OBESITY.  247. 

GENERAL  RULES  FOR  OBESITY. 

"  Guard  against  sugars,  starches,  and  excess  of  fat-forming  foods.  A  cer- 
tain amount  of  fat  with  the  food  is  essentiaL  Let  beginning  impairment  of 
the  patient's  streng-th  be  the  sign  to  give  more  liberal  diet.  Diminish  fluids, 
especially  at  meals,  when  not  more  than  five  ounces  should  be  given.  May 
substitute  saccharin  for  sugar. 

May  take: 

Soups  (very  little,  if  any). — Chicken  broth,  oyster  soup,  clam  broth, 
thin  beef-tea. 

Fish. — All  kinds  except  salt  varieties,  salmon,  or  bluefish. 

Meats. — Once  a  day  only;  lean  beef,  mutton,  chicken,  game,  veal. 

Eggs. — Boiled  and  poached. 

Farinaceous. — A  limited  amount  of  dry  toast,  aerated  bread,  shredded 
wheat  biscuit,  gluten  biscuits,  beaten  biscuits,  zwieback,  Vienna 
rolls,  soup-sticks,  crusts,  Graham  gems,  hoe-cakes. 

Vegetables  (fresh). — Asparagus,  celery,  cresses,  cauliflower,  greens, 
spinach,  lettuce,  white  cabbage,  tomatoes,  string-beans,  stuffed  pep- 
pers, radishes,  very  little  if  any  potatoes. 

Dessert. — Cheese,  grapes,  oranges,  cherries,  lemons,  currants,  apples, 
peaches,  berries,  acid  fruits,  roasted  fruits  (little  sugar). 

Beverages. — Limited  quantity  of  water,  buttermilk,  tea,  coffee  (no  sugar 
or  milk),  light  wine  diluted  with  Vichy.  Mineral  waters. — Avon 
Springs,  Eichfield  Springs,  Crab  Orchard,  Londonderry  Lithia, 
Hunyadi,  Carlsbad,  Friedrichshall,  Eubinat,  Puellna,  Villacabras. 
Continue  for  several  weeks  drinking  one  glass  of  Kissingen  water 
thirty  minutes  after  each  meal  one  day,  and  one  glass  of  Vichy 
water  similarly  the  next.     May  use  artificial  compounds. 

Must  avoid : 

Fats  in  excess,  beverages  in  excess,  thick  soups,  salmon,  bluefish,  eels, 
herrings,  and  all  salt  fish,  pork,  sausages,  spices,  hominy,  oatmeal, 
macaroni,  potatoes,  parsnips,  turnips,  carrots,  beet-root,  rice,  water- 
melons, muskmelons,  puddings,  pies,  cakes,  sweets,  milk,  sugar, 
malt  and  spirituous  liquors. 

I  also  give  another  dietary  taken  from  Anders  (loc.  cit.),  which  illustrates 
what  may  be  ordered  in  individual  cases : 

Morning  Meal. — Fine  wheat  bread,   1^  ounces ;   a  soft-boiled  egg ;  milk, 

1  ounce ;  sugar,  77  grains ;  coffee,  4^  ounces. 
]!^oon  Meal. — Soup,  3  ounces ;  fish,  3  ounces ;  roast  or  boiled  beef,  veal, 

game,  or  poultry,  6  to  8  ounces ;  green  vegetables,  1^  ounces ;  bread,  1 

ounce;  fruit,  3  or  4  ounces;  no  liquid  (or  only  4  or  5  ounces — 120.0- 

148.0  c.c.  of  very  light  wine). 


248  CONSTIPATIOlSr.        nEADACHE.       INSOMNIA,       OBESITY, 

Afternoon   Meal. — Sugar,    Y7   grains;    coffee,    4   ounces;    milk,    1    ounce; 

occasionally  bread,  1  ounce. 
Evening  Meal. — Caviar,  ^  ounce;  one  or  two  soft-boiled  eggs;  beefsteak, 

fowl,  or  game,  5  ounces ;  salad,  1  ounce ;  cheese,  1  drachm ;  bread,  rye 

or  bran,  -J  ounce ;  fruit  or  water,  4  to  5  ounces. 

Should  there  be  a  history  of  gout  or  of  rheumatism,  a  course  of  diet  spe- 
cially applicable  must  be  made  out. 

A  good  deal  can  be  done  in  the  way  of  prophylaxis  during  childhood 
in  cases  where  the  family  history  shows  that  obesity  is  likely  to  occur  at 
maturity.  In  such  cases  careful  attention  must  be  paid  to  appropriate  exer- 
cise, systematic  daily  cold  baths,  fresh  air,  and  the  reduction  of  fats  and  fari- 
naceous food. 

There  has  been  much  talk  of  late  years  of  the  extract  of  the  thyroid 
gland  in  the  reduction  of  obesity.  In  cases  of  myxedema  it  is  known  to 
be  of  great  value  and  there  are  certain  doubtful  cases,  where  no  symptom 
of  myxedema  exists  excej^t  mental  sluggishness,  in  which  small  doses  of  the 
thyroid,  say  two  grains  three  times  a  day,  have  a  remarkable  effect.  It  is 
always  allowable  to  try  the  gland  in  such  cases,  keeping  the  patient  under 
careful  observation,  but  should  there  be  any  indications  of  injurious  effects, 
manifested  by  tachycardia,  or  irregular  heart  action,  suffusion  of  the  face, 
syncope,  vertigo,  or  marked  headache,  it  must  be  stopped  at  once.  The  indis- 
criminate use  of  the  thyroid  in  any  and  every  case  of  obesity  is  extremely 
dangerous  and  ought  not  to  be  encouraged,  as  it  acts  as  a  depressant  and  also 
causes  gastro-intestinal  disturbance. 

In  conclusion  mention  may  be  made  of  the  four  principal  methods  of 
reduction  of  obesity,  namely,  those  of  Banting,  Von  ISToorden,  Oertel,  and 
Ebstein.      The  distinguishing  characteristics  of  these  are: 

Banting  reduces  the  amount  of  farinaceous  food,  depending  almost  entirely 
upon  j)i"oteids.  Von  ISToorden  reduces  the  amount  of  food  as  a  whole,  giving 
a  large  proportion  of  meat  and  restricting  the  amount  of  sugar  and  starches; 
the  amount  of  liquids  is  also  reduced.  Oertel's  treatment  is  based  largely  upon 
the  reduction  of  liquids  to  as  small  amount  as  can  be  borne ;  the  diet  allows 
rather  more  carbohydrate  and  fatty  food  than  that  of  Banting  and  rather  less 
than  that  of  Ebstein.  Oertel  carefully  includes  the  use  of  graduated  exercises 
in  his  course  of  treatment.  Ebstein  gives  less  proteids  than  Banting,  but  more 
fat  and  carbohydrates,  in  fact,  he  allows  a  greater  proportion  of  fat  than  is 
found  in  any  other  dietary. 

ADIPOSIS    DOLOROSA. 

This  affection,  otherwise  known  as  Dercum's  disease,  is  characterized 
by  the  deposit  of  fat  in  masses  situated  in  different  parts  of  the  body,  pre- 
ceded and  attended  by  pain.  It  is  an  affection  peculiar  to  women  and  appears 
during  the  middle  period  of  life.     jSTeuralgic  pains  associated  with  the  fatty 


ADIPOSIS    DOLOROSA. 


249 


masses  occur  in  different  parts  of  the  body.  Sometimes  the  fatty  deposits 
become  so  large  that  they  form  huge  pendulous  masses ;  these  never  appear  on 
the  hands  or  feet.  This  affection  differs  from  other  varieties  of  obesity  by  the 
pain  associated  with  it  and  by  the  irregular  distribution  of  the  fat.  In  some 
cases  of  the  affection  the  thyroid  gland  has  shown  a  marked  tendency  to 
atrophy.  Dercum  states  that  he  has  seen  great  improvement  from  the  use  of 
the  thyroid  extract  in  the  treatment  of  the  disease. 


CHAPTEE    IX. 

BACKACHE.     COCCYGODYNIA. 

(1)  Backache:  Frequency,  p.  250.     Etiology,  p.  250.     Treatment,  p.  256. 

(2)  Coccygodynia:    Definition,  p.  260.     Early  cases,  p.  260.     Etiology,  p.  261.     Symptoms,  p. 

262.     Diagnosis,  p.  263.     Treatment,  p.  263. 

BACKACHE. 

Frequency. — Backache  is  one  of  the  commonest  disorders  to  which  women 
are  heirs.  Pain  in  the  back  is  not  often  felt  by  either  the  yoimg  or  the  old; 
it  seems  rather  to  belong  to  middle  life,  that  is  to  say,  to  the  period  between  the 
thirties  and  the  fifties.  The  pain  varies  in  intensity  from  a  mild  intermittent 
ache,  coming  on  when  the  patient  is  tired,  perhaps  in  association  with  a  head- 
ache to  a  suffering  of  such  intensity  that  she  feels  as  though  her  back  were 
breaking  in  two,  and  is  unable  to  rise  from  a  couch  or  chair  without  suffering, 
often  expressed  in  loud  groanings. 

Etiology. — It  is  not  my  purpose  to  make  more  than  passing  mention  of 
those  acute  lumbagos  which  come  on  after  exposure,  or  after  sweating  and 
allowing  the  wet  clothes  to  dry  on  the  back.  The  pain  in  such  cases  often 
begins  without  any  warning,  striking  the  patient  utterly  unexpectedly,  like 
a  bullet  traversing  the  lumbar  muscles  (German,  Hexenschuss).  From  that 
time  imtil  the  attack  is  over,  all  muscular  exertion  causes  pain,  often  extreme, 
and  even  agonizing.  The  best  treatment  in  such  a  case  is  rest  in  bed,  a 
hot  relaxing  bath,  or  ironing  the  lumbar  muscles  with  a  hot 
iron  as  hot  as  can  be  borne  through  flannel,  for  ten  or  fifteen  minutes.  It 
can  also  be  cured  by  thorough  deep  Swedish  massage,  the  treatments 
being  given  twice  a  day  and  continued  for  from  twenty-five  to  thirty  minutes. 
The  best  drug  is  aspirin  in  ten  grain  doses,  followed  by  four  or  five  doses 
of  five  grains  each,  at  intervals  of  an  hour.  It  is  a  good  plan,  in  some  cases, 
to  inaugurate  the  treatment  with  ten  grains  of  Dover's  powder,  to  produce  a 
free  sweat.  Sufferers  from  acute  lumbago  often  find  that  they  can  ward  off 
a  fresh  attack  by  wearing  a  flannel  bandage,  or  by  using  a  Jaeger 
wool  bandage,  made  for  this  purpose.  A  plan  of  treatment  diametrically 
the  opposite  to  this  is  absolute  fixation  of  the  affected  parts  by  strapping. 

Backaches  must  be  distinguished  according  to  their  location  as  lumbar, 
lumbo-thoracic,  sacral,  or  coccygeal  (to  be  considered  under  the  cap- 
tion coccygodynia,  page  260).  The  common  areas  of  location  of  aches 
in  the  posterior  part  of  the  lower  trunk  are:  The  coccygeal  region,  somewhat 
250 


ETIOLOGY    OF    BACKACHE.  251 

hidden  in  the  cleft  of  the  buttocks;  above  this  the  sacral  or  the  sacro-iliac 
region;  above  this  again  the  lumbar  region;  and  lastly  an  area  above  the 
lumbar  in  the  lower  thoracic  region. 

These  regions  must  always  be  considered  as  representing  the  structures 
below  the  skin,  for  example: 

1.  The  coccyx,  whether  dislocated  forwards  or  fractured,  as  well  as  the 
ligaments  attached  to  it  laterally. 

2.  The  fascia  overlying  the  sacrum  with  the  erector  spina?  muscles  and 
the  sacro-iliac  joints. 

3.  The  lumbar  fascia,  the  erector  spinae,  the  quadratus,  and  the  psoas 
muscles. 

4.  The  serratus  posticus  inferior  muscle. 

They  are  further  distinguished  according  as  the  pain  is  fixed  in  one  spot 
or  radiates.  The  direction  of  radiation  is  almost  always  downwards.  In 
some  cases  the  pain  is  central,  in  others  more  lateral,  to  right  or  left,  or  on 
both  sides. 

Patients,  as  a  rule,  consider  that  backache  is  due  to  kidney  disease, 
if  they  are  men;  or  to  uterine  disease,  if  women.  It  is  true  that  pain 
in  the  back  is  sometimes  associated  with  these  conditions,  and  care  should 
always  be  taken  to  ascertain  how  far  they  are  accountable  in  any  given  case ; 
but  the  idea,  so  firmly  fixed  in  the  lay  mind,  that  backache  is  always  attribu- 
table to  one  or  the  other  cause  is  erroneous. 

My  own  experience  teaches  me  that  a  backache  is  not  often  directly 
dependent  upon  any  pelvic  disease,  though  it  is  a  common  con- 
comitant. I  would  attribute  most  lumbar  aches  rather  to  the  neurasthenic 
or  run-down  condition  of  the  patient,  inviting  a  local  disorder  in  a  weak  spot. 

This  is  often  proven  by  the  fact  that  the  mere  correction  of  a  minor  pelvic 
ailment,  apart  from  the  care  of  the  general  condition,  does  not  do  away  with 
the  backache ;  whereas  patients  with  aggravated  pelvic  ailments,  where  we 
would  most  expect  backache,  often  do  not  complain  of  it  to  any  great  extent. 
It  is  common  to  find  backache  associated  with  pelvic  tumors  or  inflammatory 
masses  pressing  on  the  sacral  nerves  as  well  as  with  retrodisplacements  of  the 
uterus  and  chronic  constipation,  but,  as  I  have  said,  I  attribute  the  backache 
rather  to  the  general  run-down  condition  of  the  patient  than  to  the  local  intra- 
pelvic  disorder.  Backache  is  always  a  common  symptom  in  nerve  exhaus- 
tion arising  from  whatever  cause.  A  common  cause  of  the  severe  post- 
operative backache  is  the  straight-out  dorsal  posture  in  which  the  patient 
lies  during  a  long  operation.  The  pain  from  the  wrenching  of  the  lumbar 
sinews  is  often  far  more  intense  than  that  directly  associated  with  a  major 
surgical  operation. 

It  becomes  a  matter  of  the  first  moment  to  distinguish,  wherever  we  can, 
between  the  muscular  rheumatisms  of  the  sacral  region  and  the 
lower  back,  and  the  sacro-iliac  joint  affections  which  cause  similar 
pains  in  these  regions. 


252  BACKACHE.       COCCYGODYJSTIA. 

In  the  first  place,  tlie  rheumatic  trouble  may  have  come  on  as  a 
sequel  to  an  acute  attack.  Again,  pain  in  the  muscles  may  be  aroused  by 
pressure  on  the  muscles  themselves,  either  upon  the  erector  spinae,  or  into  the 
substance  of  the  erector,  the  longissimus,  the  sacro-lumbalis,  or  the  quadratus. 
The  pain  is  provoked  by  such  attitudes  as  serve  to  put  these  muscles  on  the 
stretch ;  and,  what  is  most  important,  the  pain  in  the  muscles  tends  to  get 
better  with  a  little  exercise.  The  patient  who  starts  out  with  groanings  and 
with  great  difficulty,  taking  a  halting  gait,  soon  steps  along  as  though  per- 
fectly well. 

Schreiber  ("  Die  mechanische  Behandlung  der  Lumbago,"  Wiener  Klin., 
1887,  p.  T7)  says  that  an  intense  dull  pain  widely  extended  from  the  sacrum 
to  the  third  dorsal  vertebra,  not  accompanied  by  much  limitation  in  the  move- 
ments of  the  vertebral  column,  indicates  rather  an  involvement  of  the  fascia 
lumbo-dorsalis  than  an  affection  of  the  muscles.  When  bending  is  possible, 
but  straightening  the  spinal  column  is  difficult  and  painful,  the  erectors  are 
affected.  Such  patients  preferably  sit,  or  lie  with  the  body  inclined  forward. 
On  the  other  hand,  difficult  painful  bending  forward  indicates  an  affection 
of  the  flexor  muscles,  the  quadratus  and  the  psoas.  The  psoas  affection 
is  evident  in  the  distress  occasioned  by  bringing  into  play  its  function  of 
rolling  the  thigh  outward.  "When  the  pain  is  higher,  in  the  region  of  the 
fourth  to  seventh  ribs,  not  influenced  by  bending  the  spine,  but  excited  by 
breathing,  the    serratus   posticus    is  the  affected  muscle. 

The  affections  of  the  sacro-iliac  joint  are  often  quite  different. 
The  importance  of  this  class  of  cases  was  first  fully  appreciated  by  Goldthwait 
{Bost.  Med.  and  Surg.  Jour.,  1905,  vol.  152,  pp.  593,  634),  who  attributes 
many  backaches  in  women  to  a  sacro-iliac  luxation.  The  condition  still  awaits 
recognition  at  the  hands  of  the  profession  at  large. 

Goldthwait  says  that  the  sacro-iliac  articulations  are  true  joints,  and  are 
by  no  means  as  stable  as  has  been  supposed,  so  that  under  normal  conditions, 
some  definite  motion  exists.  There  is  always  a  physiological  increase  in  this 
motion  during  pregnancy,  and  "  possibly  always,  certainly  occasionally,  dur- 
ing menstruation.  Injury,  disease,  a  general  lack  of  muscular  and  ligamen- 
tous tone,  all  are  factors  which  cause  an  excess  of  the  normal  amount  of 
motion.  ...  As  the  female  pelvis  is  less  firmly  constructed  the  mobility  is 
more  easily  obtained."  I  continue  to  quote  as  far  as  possible  from  Dr.  Gold- 
thwait's  monograph :  "  As  the  cases  are  studied,  they  at  once  divide  themselves 
into  groups :  the  first  including  those  in  which  there  is  definite  relaxation 
associated  with  pregnancy,  representing  an  exaggeration  of  a  normal  physio- 
logical condition;  the  second,  those  cases  in  which  the  relaxation  is  associated 
with  menstruation,  apparently  representing  also  a  physiological  condition,  apart 
from  any  pathological  change  with  which  we  are  at  present  familiar ;  and  the 
third,  the  cases  in  which  the  lesion  is  due  to  trauma,  general  weakness,  or 
some  definitely  known  pathological  process.  In  general,  the  relaxation  asso- 
ciated with  pregnancy  is  more  marked,  as  it  is  also  more  rapid  in  its  develop- 


AFFECTIONS    OF    THE    SACRO-lLlAC    JOINT.  253 

ment,  but  it  is  also  more  certainly  and  quickly  rectified  by  treatment  when 
the  cause  is  removed.  With  the  non-pregnant  eases  the  relaxation  is  not  as 
marked;  there  is  no  sudden  onset  with  severe  symptoms,  but  it  is  more  insid- 
ious and  also  more  troublesome  in  treatment,  as  the  apparent  cause  is  repeated 
at  the  return  of  each  menstruation.  .  .  . 

"  The  cases  which  properly  belong  to  the  third  group  are  not  only  more 
numerous,  but  many  of  the  characteristics  are  different  from  those  in  the  other 
groups.  Only  one  joint  may  be  affected  instead  of  all  three,  as  is  common  in 
the  others,  and  the  referred  pains  in  leg  and  hip  are  much  more  common  in 
this  group  than  in  those  previously  considered.  The  lateral  deformities  or 
deviation  of  the  body  to  one  side,  due  to  the  partial  displacement  of  the  bones 
on  one  side  and  not  on  the  other,  are  common.  The  onset  may  be  sudden. 
The  so-called  '  stitch '  in  the  back  following  strain  or  overwork  is  in  most 
instances  due  to  the  slipping  of  these  bones,  and  in  these  cases  the  lesion  rep- 
resents a  definite  sprain,  the  severity  of  the  symptoms  depending  upon  the 
severity  of  the  injury,  as  with  sprains  of  other  joints.  The  onset  at  other 
times  may  be  more  insidious,  and  may  be  part  of  a  definite  joint  disease,  the 
symptoms  being  due  to  weakness  resulting  from  the  disease,  or  from  the  pres- 
ence of  accompanying  bone  and  joint  structure  thickening,  the  hypertrophic 
arthritis  (osteo-arthritis)  being  the  most  common  of  these  affections. 

"  In  the  general  relaxation  which  follows  prolonged  recumbency  upon  the 
back,  the  lumbar  spine  straightens,  and  the  back  becomes  flat.  With  this, 
the  upper  portion  of  the  sacrum,  being  a  part  of  the  antero-posterior  curve 
of  the  lumbar  spine,  is  drawn  backward.  This  is  undoubtedly  the  explana- 
tion of  the  frequency  of  backache  and  leg  pain  developing  at  night  after  sleep, 
and  also  explains  the  more  common  backache  after  operations  in  which  the 
profound  relaxation  produced  by  the  anesthetic,  together  with  the  straight  hard 
table,  make  the  joint  strain  inevitable.  The  common  way  of  relieving  the 
night  pain  by  stretching  upon  first  waking,  which  draws  the  lumbar  spine 
forward,  is  also  understood  with  this  knowledge  of  the  anatomy.  ... 

"  At  times  the  lesion  apparently  represents  simply  an  excess  of  a  normal 
physiological  process.  At  other  times  trauma  is  a  definite  factor,  '  sitting 
down  hard,'  or  the  '  giving  way '  under  severe  strains,  such  as  lifting,  being 
the  two  most  common  forms  of  injury.  Attitudes  or  postures  are  also  of  im- 
portance in  causing  a  predisposition  to  joint  weakness  or  displacement.  .  .  . 

"  In  stout  persons,  either  men  or  women,  the  drag  of  the  large  abdomen 
causes  lordosis  with  resulting  pelvic-joint  strain,  and  explains  the  frequency 
of  the  sacro-iliac  weakness  in  this  type  of  individual.  In  this  connection, 
imdoubtedly,  the  present  so-called  straight-front  corset,  if  tightly  worn,  must 
be  harmful  by  causing  an  unnatural  amount  of  lordosis  and  by  producing  too 
great  pressure  upon  the  anterior  portion  of  the  iliac  crests.  .   .  . 

"  Any  motion  in  which  the  trunk  or  thigh  muscles  are  used,  whatever  the 
position  of  the  body,  necessarily  causes  the  bones  to  slip  about  or  the  joint 
to  be  strained.     In  the  severest  cases  standing  or  walking  is  impossible,  the 


254  BACKACHE.       COCCYCtODYNIA. 

patients  describing  the  sensation  as  '  breaking  apart  in  the  middle/  or  as  the 
body  '  settling  down  into  the  thighs.'  With  some  the  npright  position  and 
even  walking  is  possible  only  for  a  few  minutes,  the  bones  apparently  being 
held  by  strong  muscular  effort,  but  as  soon  as  this  relaxes,  either  from  fatigue 
or  in  unexpected  motion,  the  helplessness  at  once  returns.  In  the  mildest 
cases  the  symptoms  have  been  so  vague  that  the  exact  nature  of  the  difficulty 
has  been  appreciated  only  by- a  most  careful  process  of  elimination. 

"  Of  the  symptoms  which  have  been  associated  with  this  condition  there 
is  apparently  quite  a  wide  range.  In  the  most  extreme  degree  of  relaxation 
or  disease  the  helplessness  is  profound,  nothing  but  recumbency  being  possible, 
while  the  slightest  motion,  such  as  raising  the  knee  or  moving  the  foot,  is 
associated  with  definite  movement  of  the  pelvic  joints  and  consequent  pain 
and  discomfort.  A^Hien  perfectly  quiet  there  is  little  pain  other  than  back- 
ache, and  this  is  worse  after  sleep,  during  wdiich  the  spinal  muscles  become 
relaxed  and  the  joint  strain  is  increased.  All  three  of  the  pelvic  articulations 
may  be  tender  to  pressure,  and  the  abnormal  mobility  may  be  easily  demon- 
strable. In  some  of  the  cases  sitting  is  impossible  unless  the  weight  of  the 
body  is  supported,  usually  by  placing  the  elbows  on  the  knees  or  by  holding 
the  seat  of  the  chair  with  the  hands.  On  walking,  the  movement  of  the  but- 
tocks up  and  down  may  be  quite  evident. 

"  In  the  cases  in  which  the  relaxation  or  disease  is  less  marked  the  symp- 
toms vary  more,  both  as  to  the  nature  of  the  special  symptoms,  and  as  to  their 
constancy.  At  times,  only  at  the  menstrual  period  is  there  any  trouble  or  are 
the  symptoms  severe  enough  to  cause  much  inconvenience. 

"  Probably  the  most  common  complaint  is  of  backache,  referred  at  times 
definitely  to  the  sacro-iliac  articulations,  but  often  simply  to  the  sacral  region. 
This  is  usually  worse  on  lying  upon  the  back  or  with  any  back-straining  exer- 
cise or  occupation  carried  to  the  point  of  fatigue.  When  lying  upon  the  back, 
the  flattening  of  the  lumbar  spine  necessarily  strains  the  sacro-iliac  ligaments 
and  is  evidently  the  cause  of  the  backache.  As  this  takes  place  only  when 
the  muscles  are  relaxed,  it  explains  the  pain  developing  during  sleep,  the 
patient  often  being  wakened  with  the  severe  suffering.  This  is  usually  relieved 
by  stretching  or  by  some  other  change  of  position  in  which  the  lumbar  spine 
and  the  sacrum  are  drawn  up.  The  backache  which  develops  when  the  patient 
is  up  and  about  may  be  brought  on  by  any  posture  which  causes  strain  on  the 
sacral  ligaments,  such  as  lounging,  sitting  with  the  lumbar  spine  thrown  back, 
or  prolonged  standing  and  walking.  At  times  the  backache  is  produced  by  a 
jar  or  by  some  sudden,  misstep  in  which  the  muscles  are  taken  off  their  guard. 
At  such  times  there  is,  as  a  rule,  a  distinct  sensation  of  slipping  or  giving 
out,  and  the  leg  may  actually  '  give  way,'  just  as  the  knee  joint  locks  or 
'  gives  w^ay  '  if  caught  with  a  loose  cartilage.  The  pain  or  backache  may 
be  referred  to  one  synchondrosis  or  both,  and  with  this  there  may  be  discom- 
fort referred  to  the  symphysis.  In  the  cases  in  which  the  pain  has  been 
referred    at   first  to   one   synchondrosis   there   has   nearly    always    developed, 


AFE'ECTIONS    OF    THE    SACEO-ILIAC    JOiNT.  255 

sooner  or  later,  a  similar  condition  upon  the  other  side,  although  frequently 
of  less  severity. 

"  Referred  pains  are  quite  common,  and  are  probably  due  to  the  pressure 
or  pull  upon  the  nerves  in  the  sacral  region.  The  lumbo-sacral  cord  passes 
directly  over  the  upper  part  of  the  sacro-iliac  articulation,  and  it  is  easy  to 
see  that  a  slight  displacement  or  the  thickening  or  nodes  resulting  from  dis- 
ease might  cause  pressure  upon  this  nerve  trunk.  Undoubtedly  the  pressure 
or  irritation  of  the  nerve  received  in  this  way  causes  many  of  the  pains 
referred  to  the  leg.  They  may  be  referred  to  any  part  below  the  seat  of  the 
trouble,  to  the  thigh,  the  hip,  the  calf,  or  down  the  back  of  the  leg  following 
the  sciatic  distribution.  These  pains  are  practically  always  more  upon  one 
side  than  the  other,  but  usually  both  sides  are  somewhat  affected,  and  this, 
together  with  the  fluctuation  in  the  character  of  the  pain,  suddenly  coining  on 
or  passing  off,  is  of  importance  in  differentiating  between  this  condition  and 
other  conditions  in  which  leg  pains  occur.  That  the  nerves  are  pressed  upon 
or  irritated  is  not  to.  be  wondered  at  when  the  anatomy  is  considered.  In  fact, 
in  any  displacement  which  may  occur,  or  in  the  hypertrophic  arthritic  thick- 
ening^ the  edge  of  the  bone  is  so  exposed  that  pressure  or  irritation  of  the 
nerve  is  almost  to  be  expected.  The  severity  of  the  pain  is  at  times  very 
great.  In  two  of  the  patients  it  was  so  intense  that  lying  down  was  impossible 
and  the  nights  were  spent  pillowed  up  in  chairs, 

"  Objective  Symptoms :  The  objective  symptoms  are  such  as  would  be 
expected  from  our  knowledge  of  the  condition.  The  motions  which  would 
bring  strain  ,upon  the  weak  part  are  guarded,  in  the  severe  cases  this  reflex 
guarding  leading  to  great  disability.  It  may  be  impossible  without  assistance 
to  get  up  or  to  lie  down.  Stooping  is  always  made  guardedly  and  in  the  severe 
cases  this  may  be  impossible  unless  the  knees  are  flexed  and  the  spasm  of  the 
hamstring  muscles  released.  On  standing,  if  the  sacrum  is  at  all  displaced, 
the  lumbar  curve  of  the  spine  may  be  obliterated  or  even  reversed ;  the  whole 
attitude  being  suggestively  peculiar.  If  one  side  is  more  involved  than  the 
other,  a  marked  lateral  deviation  of  the  body  may  be  present,  this  always 
being  away  from  the  affected  joint.  A  slight  degree  of  this  lateral  deviation 
is  very  common. 

"  Forward  bending,  if  attempted  when  standing  with  the  knees  straight, 
is  limited,  but  is  always  more  free  if  the  knees  are  flexed,  as  when  sitting. 
In  the  first  position  the  hamstring  muscles  which  are  attached  at  the  tuberosity 
of  the  ischium  are  made  tense,  and  by  causing  strain  upon  the  sacro-iliac 
articulations  develop  the  muscular  spasm.  .  .  .  The  character  of  the  disease 
will  be  determined  by  the  general  appearance  of  the  patient  and  the  appear- 
ance locally;  that  is,  the  presence  or  absence  of  an  abscess,  the  presence  or 
absence  of  a  tumor  suggesting  a  new  growth,  and  the  presence  or  absence  of 
the  same  disease  in  other  joints.  In  the  hypertrophic  arthritic  process,  which 
is  by  far  the  most  common  form  of  disease  seen  in  the  sacro-iliac  articula- 
tions, there  almost  always  is  at  the  same  time  disease  of  the  spine  with  the 


256  BACKACHE.   COCCYGODYXIA. 

limitation  of  motion  and  other  symptoms  characteristic  of  the  disease  in  that 
region." 

]\Iore  recently  Goldthwait  (Bost.  Med.  and  Surg.  Jour.,  1911,  March 
16)  has  shown  how  weakness  or  partial  displacement  of  the  lumbosacral  ar- 
ticnlation,  with  resulting  pressure  on  the  cauda  equina  or  nerve  roots,  is  respon- 
sible for  many  cases  of  "  lumbago,"  "'  sciatica  "  and  "  paraplegia." 

Other  causes  of  backache  must  also  be  borne  in  mind.  For  example,  acute 
infectious  processes,  such  as  typhoid  fever  and  a  gonorrheal  arthritis. 
An  agonizing  backache  is  one  of  the  most  characteristic  symptoms  of  the  onset 
of  small-pox.  Congenital  deformities  and  osteo-arthritis  due  to 
spondylolisthesis  also  give  rise  to  distressing  and  persistent  pain  in  the  back. 

Treatment.- — I  shall  speak  first  of  the  sacro-lumbar  rheumatic  affec- 
tion, in  which  it  is  important,  first  and  foremost,  not  to  promise  that  a 
speedy  cure  will  follow  the  relief  of  any  co-existing  minor  ailment,  such  as 
an  anteflexion,  a  laceration  of  the  cervix,  or  a  retroflexed  uterus.  It  may  he 
necessary  to  correct  these  errors  (except  the  anteflexion),  but  the  patient  must 
be  forewarned  that  the  backache  will  take  longer  to  relieve. 

Whatever  local  measures  are  employed,  general  tonic  hygienic  means 
must  also  be  used  to  build  up  the  health  and  to  rest  and  feed  the  tired  nerves. 
For  this  purpose  give  nux  vomica,  beginning  with  a  few  drops  (five)  three 
times  a  day  in  water  and  increasing  daily  by  three  drops  until  twenty  or 
twenty-five  are  reached.     I  find  useful  a  pill  made  after  this  prescription : 

^   Ex.  calumbse 


aa gT.  J 

Ex.  gentian     ) 

M.     ft.  pil.  1.  S.     Take  one  pill  after  each  meal. 

Dr.  C.  G.  Hollister  {Med.  and  Surg.  Reporter,  1888,  vol.  58,  p.  201) 
found  marvelous  relief  in  a  series  of  cases  treated  with  this  prescription: 

^   Pot.  iodidi    8ss. 

Pot.  bromidi Sss. 

Tr.  colchici  sem fojss. 

Syr,  aurantii  cort foij 

Aquae  q.   s.  ad f ovj 

M.      Sig.     One  teaspoonful  three  or  four  times  a  day,  or  oftener,  until 
the  bowels  are  slightly  acted  upon. 

Massage  is  one  of  the  best  methods  of  treating  backache,  but  it  must 
not  be  given  in  the  form  of  mere  superficial  skin  frictions;  the  trained  fingers 
and  thumbs  must  first  seek  out  the  painful  spots  and  then  skilfully  and  thor- 
oughly rub  them,  so  as  to  increase  the  local  circulation  and  thereby  dissipate 
the  morbid  products  in  muscle  and  nerve  sheaths. 

In  order  to  give  the  massage  effectively,  the  patient  lies  flat  on  the  abdomen 
on  a  hard  mattress  laid  on  the  floor,  or  on  a  low  bed.  It  cannot  be  properly 
given  on  a  soft  yielding  bed,  which  lacks  sufficient  resistance,  and  dissipates 


TREATMENT    OF    BACKACHE.  257 

the  force  applied  to  the  muscles  of  the  back.  It  is  not  necessary  to  remove 
all  the  clothes ;  the  best  material  between  the  hand  of  the  masseur  and  the 
patient  being  sheep's  wool.  Kneeling  close  by  the  patient  on  the  floor  or 
standing  at  the  side  of  the  couch,  the  masseur  kneads  the  painful  structures 
overlying  the  sacrum,  or  in  the  lumbar  regions,  taking  care  to  avoid  making 
any  marked  pressure  directly  on  the  bone  itself.  In  the  beginning  only  mod- 
erate strength  should  be  used,  but  the  pressure  must  gradually  be  increased 
to  a  maximum,  at  first  with  the  tips  of  the  fingers,  then  the  knuckles,  and 
finally  the  whole  fist.  The  kneading  movements  are  followed  by  hacking  mo- 
tions, in  which  the  muscles  are  struck  with  the  side  of  the  open  hand,  the  force 
being  increased  from  piano,  through  forte,  to  fortissimo.  In  giving  the  knead- 
ing movements,  the  masseur  works  most  comfortably  on  the  same  side  as  the 
structure  under  treatment,  while  in  giving  the  hacking  movements,  he  operates 
best  across  the  patient.  It  is  most  important,  says  Schreiber,  whose  description 
I  am  following  as  closely  as  possible,  to  persist  in  giving  the  active  local  treat- 
ment in  those  very  places  where,  according  to  the  statement  of  the  patient, 
the  pain  is  most  sharply  felt.  When  the  deepest  muscles  are  involved,  such, 
for  instance,  as  the  multifidi  spinse,  as  evidenced  by  the  great  difficulty  or 
impossibility  of  rotating  the  spinal  column,  pressure  movements  must  be  used 
which  demand  all  the  strength  of  the  operator,  using  not  only  his  hand,  but 
the  entire  weight  of  his  body.  The  hacking  movements  are  not  made  from  the 
shoulder  joints  but  from  the  elbow.  The  amount  of  force  used  will  depend 
upon  the  grade  of  the  trouble,  and  upon  the  character  of  the  muscular  struc- 
tures under  treatment,  as  well  as  upon  the  amount  of  subcutaneous  fat,  and 
the  experience  of  the  physician.  Any  little  periods  of  rest  in  the  treatment 
may  be  employed  to  test  the  progress  made ;  if  the  patient  feels  pain,  the  treat- 
ment must  be  begun  again  and  directed  to  the  painful  spot.  The  following 
movements  are  to  be  recommended: 

Sitting  and  rising  from  a  chair,  a  divan,  a  stool,  without  the  assistance 
of  the  arm. 

Bending  over. 

Lifting  up  objects,  without  bending  the  knees. 

Sitting  and  putting  on  the  shoes. 

Standing  and  putting  on  drawers. 

Climbing  up  onto  a  stool. 

Climbing  up  onto  a  chair. 

Jumping  down  from  the  stool. 

Jumping  down  from  the  chair. 

Bending  pelvis  forwards,  backwards,  sideways. 

Making  circular  movements  with  pelvis. 

Climbing  over  a  staff. 

Schreiber  recommends  that  these  movements  should  be  repeated  ten  times. 
While  at  first  they  cause  lively  pain,  this  disappears  in  about  half  an  hour, 
and  they  can  be  done  without  any  suffering  at  all. 
18 


258 


BACKACHE.       COCCYGODYNIA. 


Those  who  are  inclined  to  feel  despondent  over  the  treatment  of  an  invet- 
erate lumbago,  would  do  well  to  recall  the  emphatic  statement  of  Schreiber, 
namely,  that  his  collective  experiences  justify  him  in  the  assertion  that 
every  muscular  rheumatism,  whether  acute  or  chronic,  wherever 
it  is  located,  can  be  healed  by  mechano-therapy.  Even  cases  of 
twenty  years'  standing  are  susceptible  of  the  relief  of  the  25ain  and  the  com- 
plete restoration  of  function  within  a  relatively  short  time. 

A  good  liniment  for  the  patient's  use  is  chloroform  and  aconite 
liniment.  Some  patients  are  benefited  by  a  coarse  salt  rub,  night 
and  morning.  Great  relief  is  experienced  for  a  time  by  the  application  of 
the  familiar  hot- water  bag,  though  it  is  not  curative.  I  used  to  relieve 
my  patients  for  a  long  period,  and  in  many  cases  effect  a  cure,  by  brushing 
the  affected  area  lightly  six  to  eight  times  with  the  Paquelin  cautery 
heated  to  a  cherry-red  heat.  If  passed  quickly  over  the  surface  the  cautery 
never  blisters,  but  leaves  behind  a  slightly  red  streak.  Some  patients  dread 
the  notion  more  than  the  thing  itself.  This  treatment  may  be  used  every 
five  to  seven  days. 

Static  electricity  has  been  used  with  beneficial  results  in  many  cases. 
Where  all  other  means  have  failed,  the  disease  has  been  treated  by  the  injec- 
tion of  five  milligrams  of  cocain  in  solution  under  the  arachnoid 
of   the    spinal    column,    with    instant    relief. 


Fig.  74. — Shows  Method  of  Applying  the  Thermo-light  for  Backache.     Note  the  convenient 
Sims'  lateral  posture  of  the  patient  and  the  distance  of  the  light  from  the  back. 

A  method  which  relieves  perfectly  and  permanently  a  large  percentage  of 
cases,  is  to  use   heat   and  light   rays   by  means  of  a   thirty-two    candle 


TREATMENT    OF    SACEO-ILIAC    AFFECTIOlSrS.  259 

power  electric  light  in  a  large  parabolic  reflector  (sec  Fig.  74:). 
This  may  be  applied  for  about  ten  minutes  every  day,  shifting  the  light  over 
the  surface  when  it  grows  too  hot  in  one  place.  If  the  skin  is  covered  with  a 
wet  towel  the  treatment  is  more  easily  borne ;  the  moisture  shuts  off  some  of 
the  heat  rays,  but  does  not  interfere  with  the  chemical  rays.  Patients  invari- 
ably express  themselves  as  greatly  relieved  at  once  and  usually  go  on  improving 
day  by  day. 

In  many  of  the  cases  much  relief  has  been  obtained  by  using  woven 
elastic  trunks,  fitted  about  each  thigh,  and  then  about  the  buttocks.  These 
are  laced  or  buckled,  so  that  the  pressure  may  be  controlled,  and  represent  one 
of  the  most  reliable  of  the  various  supports. 

Another  support  and  one  which  has  probably  been  more  satisfactory  than 
any  other,  except  perhaps  the  elastic  trunks,  has  been  devised  by  R.  B.  Osgood. 
It  consists  of  a  sacral  pad  to  which  a  spring  steel  crib  is  attached. 
The  ends  of  the  crib  curve  backward,  and  to  these  wide  webbing  belts  are 
attached,  which,  when  fastened  in  front,  crowd  the  sacral  pad  firmly  against 
the  upper  half  of  the  sacrum  because  of  the  curve  in  the  crib  part  of  the  brace. 
The  brace  is  kept  in  place  by  attaching  it  to  the  corsets  by  means  of  steels, 
and  these  not  only  hold  the  brace  down,  but,  by  steadying  the  lumbar  spine, 
at  the  same  time  lessen  the  tendency  to  strain  the  sacro-iliac  joints.  In  order 
to  keep  the  brace  in' place  when  sitting,  a  narrow  strap  is  attached  at  the  base 
of  the  crib,  which  is  tightened  when  the  thighs  are  flexed  and  prevents  the 
brace  from  springing  away  from  the  body.  This  brace,  in  connection  with 
the  elastic  trunk,  has  given  relief  in  the  severe  cases  when  either  alone  was 
not  satisfactory. 

Sacro-iliac  Disease. — In  sacro-iliac  disease,  proper  support  must  be  given  to 
the  pelvis.  Goldthwait's  treatment  for  the  sacro-iliac  cases  varies  according 
to  the  extent  and  the  pathology  of  the  lesion.  The  malposition,  as  he  has  dis- 
covered, is  a  backward  subluxation  of  the  upper  part  of  the  sacrum,  either 
unilateral  or  bilateral,  the  correction  of  which  may  be  brought  about  in  sev- 
eral ways.  Sometimes  the  patient  is  greatly  relieved  by  lying  at  night 
on  a  firm  bed  with  a  firm  hair  pillow  under  the  hollow  of  the 
back.  In  the  more  severe  cases  Goldthwait  has  succeeded  in  correcting  the 
luxation  by  extending  the  spine,  the  legs  resting  on  one  table, 
and  the  head  and  shoulders  on  another,  with  the  face  down- 
wards and  the  body  hanging  unsupported  between.  The  sacrum 
is  thus  replaced  and  a  plaster  jacket  is  applied.  In  cases  of  recent  injury, 
rest  may  be  enjoined  and  later  a  removable  jacket  applied,  to  be  worn  for 
several  months.  In  the  joint  strains  or  the  relaxations  without  displacements 
of  the  bones,  which  represent  the  greatest  number  of  cases,  some  sort  of  firm 
support  to  the  pelvic  bones  is  all  that  is  necessary,  and  there  need  be  little 
interruption  to  the  activities  of  daily  life.  Goldthwait  employs  a  spring 
steel  brace,  extending  up  the  spine  and  so  adjusted  as  to  make  firm  pressure 
over  the  sacrum.     In  other  cases  in  women,  a  wide  webbing  belt  attached 


260  BACKA.CHE.       COCCYGODTNIA. 

to  the  base  of  the  corsets  and  kept  up  by  the  insertion  of  light 
steels  gives  enough  pelvic  support  to  ntford  relief.  8nch  belts  are  made 
more  efficacious  by  attaching  a  lirm  pad  in  the  back  so  as  to  make  pressure 
over  the  upper  part  of  the  sacrum. 

I  have  cited  Goldthwait  in  detail  in  order  to  aid  in  placing  this  important 
matter  before  the  profession  at  large  and  to  stimulate  investigation  into  a 
class  of  ailments  Tvhich,  although  common,  has  not  hitherto  been  recognized. 
The  practitioner  may  not  feel  inclined  himself  to  undertake  treatments  so 
decidedly  orthopedic  in  their  nature,  but  it  is  at  least  important  that  he  should 
discern  these  affections  as  a  cause  of  backache,  and  be  able  intelligently  to 
secure  the  cooperation  of  a  specialist  in  bringing  relief  to  a  patient  "who  must 
otherwise  continue  to  suffer  indefinitely. 

The  distressing  post-operative  backaches  can  be  avoided  by 
keeping  the  limbs  and  the  body  slightly  flexed  during  an  opera- 
tion, by  using  pads  and  cushions  under  shoulders  and  knees,  and, 
above  all,  under  the  small  of  the  back.  Anyone  who  will  try  lying  on  a 
hard  flat  surface  without  an  anesthetic  will  find  that  it  is  a  severe,  almost 
unbearable  strain  to  remain  in  the  position  for  half  an  hour  or  more. 

COCCYGODYNIA. 

Definition. — Coccygodynia  is  a  term  coined  by  Sir  James  Y.  Simpson, 
to  designate  several  affections  whose  most  marked  characteristic  is  pain  in 
and  about  the  coccyx.  The  absence  of  any  knowledge  as  to  pathological 
conditions  associated  with  the  affection  permits  the  grouping  under  one  head 
of  several  troubles  whose  chief  feature  is  pain  in  a  common  situation. 
As  a  clinical  complaint,  coccygodynia  presents  definite  and  clear-cut  char- 
acteristics. 

Early  Cases. — The  condition  was  first  recognized  by  Dr.  J.  C.  Xott  of 
Mobile,  whose  original  publication  on  the  subject  appeared  in  the  New  Orleans 
Medical  Journal  for  May,  1844,  under  the  title  "  Extirpation  of  the  os  coc- 
cygis  for  neuralgia."  Xott's  description  of  the  clinical  symptoms  is  lively  and 
the  theories  he  advances  to  explain  the  pain  are  ingenious.  The  patient  was 
twenty-five  years  old,  unmarried,  and  what  we  should,  to-day,  call  a  neuras- 
thenic. Xott  says  "  her  condition  was  a  truly  pitiable  one.  Her  general 
health  was  completely  shattered  and  her  strength  exhausted  with  dyspepsia, 
constant  nervous  headaches,  menstruation  regular  but  difficult,  excruciating  pain 
at  the  jDoint  of  the  coccyx,  pains  in  the  uterus,  vagina,  neck  of  the  bladder, 
and  back.  The  most  prominent  symptom  was  the  exquisite  pain  at  the  point 
of  the  coccyx,  which  became  intolerable  when  she  sat  up,  walked,  or  went  to 
stool,  or,  in  short,  when  motion  or  pressure  were  communicated  to  it  in  any 
way."  This  condition  had  followed  a  blow  on  the  coccyx  four  years  pre- 
viously from  which  the  patient  recovered  after  several  weeks'  suffering,  the 
pain  not  returning  until  about  ten  months  before  she  was  seen  by  Dr.  ]^ott. 


ETIOLOGY    OF    COCCYGODYNIA.  261 

As  medicines  had  already  been  faithfully  tried,  E'ott  at  once  proposed  extir- 
pation of  the  bone  as  the  only  chance  of  relief.  The  operation  was  performed, 
of  course  without  an  anesthetic,  through  a  vertical  incision  about  two  inches 
long.  The  bone  was  disarticulated  at  the  second  joint  for  about  two  inches, 
separated  from  its  muscular  and  ligamentous  attachments,  and  so  dissected 
out  and  removed.  'Nott  observes  that  the  nerves  were  exquisitely  sensitive 
and  the  operation,  though  short,  was,  he  says,  "  one  of  the  most  painful  I  ever 
performed."  The  last  bone  of  the  coccyx  was  carious  and  hollowed  out  to  a 
mere  shell,  l^ott  further  remarks,  "  this  case  is  novel  and  instructive — I 
know  of  no  one  like  it  on  record.  E^o  doubt  many  similar  cases  have  occurred 
and  their  true  nature  been  overlooked.  I  have  another  at  this  moment."  The 
result  of  ISTott's  treatment  was  an  entire  recovery. 

I  have  thus  particularly  described  this  early  case,  both  because  I  wish  to 
do  credit  to  an  able  surgeon,  one  of  the  most  original  of  our  American  pioneers, 
and  because,  aside  from  the  antiseptic  precautions  which  would  now  be  present, 
the  operation,  as  done  to-day,  does  not  differ  in  any  important  particular  from 
its  prototype  in  Nott's  hands  sixty-four  years  ago. 

Sir  James  Y.  Simpson  first  disseminated  a  knowledge  of  coccygodynia  and 
he  also  operated  for  its  relief  by  cutting  the  ligaments  of  the  sides  of  the 
coccyx.  His  earliest  publication  on  the  subject  was  in  the  Medical  Press  and 
Circular  for  July,  1859 ;  a  full  account  is  also  given  in  his  "  Clinical  Lectures 
on  Diseases  of  Women,"  published  in  1863.  Simpson's  publications  were  fol- 
lowed at  this  time  by  others  on  the  same  subject,  but  of  late  the  affection  has 
fallen  into  undeserved  neglect,  little  attention  being  paid  to  it  except  in  quack 
advertisements,  as  can  be  seen  by  looking  through  the  Index  Medicus  for  the 
last  five  years. 

Etiology. — Coccygodynia  is  peculiarly  a  disease  of  women;  I  do  not  know 
of  any  disease,  affecting  an  organ  common  to  both  sexes,  which  is  so  exclusively 
feminine.     Beigel,  as  long  ago  as  18Y5,  noted  that  it  occurred  in  children. 

Many  cases  begin  with  a  fall  upon  the  coccyx  or  a  blow  in  which  it 
is  struck;  in  most  of  my  cases  such  a  history  was  given,  though  no  fracture, 
dislocation,  or  necrosis  of  the  bone  was  found  at  operation.  A  common  source 
of  injury  to  which  patients  frequently  attribute  the  trouble,  is  horseback 
riding  ;  one  of  Simpson's  cases  suffered  intensely  for  years  after  a  fall  from 
a  horse.  Pregnancy  and  labor  are  important  factors,  though  not  so 
influential  as  Scanzoni  believed,  for  he  states  with  emphasis  that  thirty-four 
cases  observed  by  him  had  all  borne  children.  But  in  seven  successive  cases 
which  I  operated  upon  at  the  Johns  Hopkins  Hospital,  three  were  unmarried, 
one  had  never  had  a  child,  and  in  not  one  of  the  other  three  was  there  a  his- 
tory of  an  instrumental  or  even  of  a  severe  labor. 

The  close  analogy  of  coccygodynia  with  rheumatic  pain  in  the  fascia 
and  muscles  above,  must  be  borne  in  mind,  for  it  is  within  the  range  of  pos- 
sibility that  the  affection  may  prove  to  be  one,  not  of  the  bone,  but  of  the 
tendinous  structures.     Rheumatism   has  been  assigned  as  the  cause  in  many 


262  BACKACHE.   COCCYGODYKIA. 

instances,  and  in  one  of  Simpson's  cases  the  pain  began  from  sitting  upon  the 
damp  gTOund. 

Coccygodynia  is  often  associated  with  uterine  and  other  pelvic  ail- 
ments, although  I  do  not  believe  there  is  any  direct  causal  relationship,  what 
connection  exists  being  j)robably  an  indirect  one  through  the  general  impres- 
sion made  upon  the  health  and  the  consequent  neurasthenia.  Proctitis 
and  various  rectal  complaints  occasionally  cause  disturbances  similarly 
referred. 

'Noit  called  the  affection  "  a  neuralgia  of  the  coccyx "  and  M.  Graefe 
comes  back  to  the  same  interpretation,  declaring  after  a  careful  study  of  his 
cases,  all  of  whom  had  borne  children,  that  he  does  not  believe  it  is  due  merely 
to  the  trauma  of  labor,  but  that  consecutive  changes  in  the  coccygeal  plexus 
are  to  blame  which  are  analogous  to  intercostal  neuralgia,  but  as  little  capable 
of  macro-  or  microscopical  demonstration.  SeeligTuiiller,  in  Eulenburg's  Eeal 
Encyclopedie,  under  the  caption  "  Coccygodynia,"  follows  Graefe's  idea  and 
gives  the  affection  an  equivalent  name,  "  l^euralgie  des  Plexus  Coccygeal." 

I  have  cited  these  different  opinions  as  to  etiology,  because  here  as  else- 
where, the  rational  treatment  must  go  hand  in  hand  with  our  convictions  as 
to  the  cause.  In  a  general  way  it  may  be  said  that  nervous  people  are  most 
subject  to  the  complaint,  but  it  not  infrequently  appears  in  those  who  show 
no  other  sign  of  a  neurosis. 

Symptoms. — The  essential  symptom  of  coccygodynia  is  pain  in  and  around 
the  coccyx.  Its  intensity  varies  all  the  way  from  a  mere  suggestion  or  a  dull 
aching,  to  excruciating  suffering,  requiring  morphin  for  its  relief.  The  pain 
may  be  intermittent,  but  it  is  usually  continuous,  with  an  intensity  which 
varies  greatly  from  day  to  day.  The  onset  is  usually  gradual,  but  not  by  any 
means  always.  The  act  of  sitting  down  or  rising  always  exaggerates 
the  pain,  and  in  some  cases  sitting  becomes  unbearable;  so  that  it  has  been 
called  "  the  sitting  pain."  In  one  of  my  patients  this  annoyance  was  met  by 
having  a  hole  cut  in  the  chair  upon  which  she  was  accustomed  to  sit.  But  it 
is  not  always  possible  to  provide  such  a  convenience,  and  the  sufferer  may  be 
driven  to  sit  uneasily,  first  on  one  hip  and  then  on  the  other.  Occasionally 
in  walking  each  step  brings  on  a  twinge  of  pain  and  the  patient  is  grad- 
ually reduced  to  a  sedentary  existence. 

The  act  of  defecation  is  almost  always  associated  with  increased  dis- 
comfort. Most  patients  with  coccygodynia  find  the  trouble  worse  in  preg- 
nancy. In  one  of  my  cases  it  was  severe  at  such  times,  but  almost  absent  in 
the  intervals. 

The  causes  at  work  in  a  given  case  of  coccygodynia  cannot,  as  a  rule,  be 
ascertained.  It  is  certain  that  the  majority  of  cases  are  not  dependent  upon 
abnormal  length  or  mobility  of  the  coccyx,  nor  upon- fractures,  dislocations, 
or  anchylosis  or  necrosis  of  the  bone.  Anchylosis  is  too  common  a  condition, 
for  Hvrtl,  in  a  collection  of  one  liuudro(l  and  eighty  coccyges,  found  there 
were  thirtv-two  in  which  a  luxation  and  a  consecutive  ancliylosis  was  present. 


DIAGNOSIS    AND    TREATMENT    OF    COCCYGODYNIA.  263 

!Kott,  the  pioneer  in  this  field,  was  inclined  to  lay  great  stress  upon  mechanical 
conditions. 

Diagnosis. — Coccygodynia,  in  its  milder  grades,  is  quite  common,  but  the 
severe  cases  are  rare.  Although  little  attention  is  paid  to  it  by  the  profession, 
it  is  astonishing  how  well  known  it  is  to  the  laity.  There  is  scarcely  a  com- 
munity without  its  well-known  sufferer  from  "  elongated  spinal  column," 
"  fractured  or  dislocated  coccyx,"  or  some  similarly  named  malady ;  this  is 
probably  due  largely  to  the  dissemination  of  quack  literature.  The  condition 
is  readily  discovered  on  examination,  in  which  the  patient  should  lie  in  the 
dorsal  or  the  left  lateral  posture;  the  index  finger  is  then  introduced  into  the 
rectum,  and  the  coccyx  grasped  between  the  thumb  and  finger.  Movement  of 
the  coccyx  often  reproduces  the  pain  exactly.  A  further  thorough  examina- 
tion must  be  made  of  the  pelvic  organs  in  order  to  exclude  disease  there. 

Treatment. — The  treatment  of  a  coccygodynia  will  depend  upon  the  severity 
of  the  case.  In  the  lighter  forms  much  can  be  accomplished  by  mild  meas- 
ures, such  as  proper  hygienic  and  medical  remedies,  while  the 
severer  cases,  as  a  rule,  yield  readily  to  surgical  treatment.  In 
addition  to  these  measures,  faradization  may  be  used.  By  this  means, 
Graefe  (Zeitschr.  f.  Geh.  u.  Gyn.,  1888,  vol.  15,  p.  344)  cured  all  his  cases, 
five  of  them  in  from  five  to  eight,  and  the  sixth  after  twelve  sittings.  One 
pole  is  applied  to  the  sacrum  and  one  to  the  coccyx  and  the  surrounding  tis- 
sues. Seeligman  put  one  pole  in  the  vagina,  and  so  cured  a  violent  case  of 
twelve  years'  standing  with  a  single  treatment.  Bearing  in  mind  the  close 
analogy  of  this  disease  to  the  lumbago  group  of  affections  described  in  the 
preceding  section,  a  thorough-going  massage  treatment  ought  to  be  faith- 
fully tried  before  resorting  to  surgery. 

If  these  gentler  means  fail  to  persuade  the  pain  to  let  go  its  hold,  then 
surgery  comes  in  as  a  boon,  as  the  operation  of  removing  the  coccyx  is 
neither  difficult  nor  dangerous. 

Simpson's  operation  of  election  consisted  simply  in  freeing 
the  coccyx  from  all  its  muscular  and  fascial  attachments  ;  by 
this  means  he  cured  a  number  of  cases,  but  it  is  technically  as  difficult  as  and 
less  certain  than  the  removal  of  the  coccyx.  In  bad  cases  of  coccygodynia, 
the  removal  of  the  coccyx  is  almost  always  curative.  I  relate  the  following 
illustrative  case:  Miss  M.,  age  twenty-six,  Johns  Hopkins  Hospital,  June,  1899. 
The  patient  complained  of  dysmenorrhea  and  a  severe  pain  in  the  coccyx.  She 
came  of  a  healthy,  in  no  way  neurotic  family,  and  had  always  been  well  up 
to  the  time  her  present  trouble  began.  The  dysmenorrhea  had  been  present 
four  years  and  the  pain  in  the  coccyx  about  one  year.  Formerly,  menstrua- 
tion had  been  entirely  painless ;  it  was  always  regular.  The  pain  in  the 
coccyx  was  associated  with  a  sense  of  fulness  and  swelling;  since  its  onset  it 
had  grown  steadily  worse,  until  it  was  impossible  for  her  to  sit  do\ATi  directly 
on  the  bone,  and  movement  of  the  bowels  was  extremely  painful.  The  great 
discomfort  constantly  endured   was   gradually   producing  nervous  exhaustion. 


264  BACKACHE.   COCCYGODYNIA. 

Physical  examination  showed  a  well  nourished  and  fully  developed  woman, 
with  a  retroflexed  uterus,  movable,  and  normal  in  size,  normal  tubes  and 
ovaries.  The  coccyx  was  of  normal  size  and  position  and  not  very  movable; 
it  was,  however,  exquisitely  sensitive  to  pressure  or  the  least  movement.  In 
view  of  these  findings,  the  cervix  was  dilated  and  the  uterus  suspended,  hoping 
that  the  relief  of  the  intra-pelvic  condition  would  also  relieve  the  coccygodynia. 
In  this  I  was  disappointed,  as  she  was  in  no  way  improved;  so  I  operated 
again  and  removed  the  coccyx.  The  wound  healed  j)romptly,  and  the  opera- 
tion gave  complete  relief.  The  patient  married  later,  has  had  several  children, 
and  remains  in  perfect  health. 

Sedatives  and  analgesics,  such  as  morphin  and  cocain,  ought  always 
to  be  employed  with  the  greatest  care,  as  they  only  afford  temporary  relief 
and  are  liable  to  induce  a  pernicious  habit  worse  than  the  disease  itself. 


CHAPTER    X. 

ACUTE  INFECTIOUS   DISEASES  AS  A   CAUSE   OF   PELVIC   DISEASE. 

(1)  Atresia  of  the  vulva  and  vagina,  p.  265. 

(2)  Inflamniation  of  the  ovaries  and  uterus,  p.  268. 

(3)  Malaria  and  disease  of  the  pelvic  organs,  p.  271. 

(4)  Metastases  to  the  sexual  organs  during  parotitis,  p.  272. 

ATRESIA    OF    THE    VULVA    AND    VAGINA. 

It  is  now  a  well-recognized  fact  that  atresias  of  the  genital  tract,  hitherto 
supposed  to  be  congenital  in  all  but  the  rarest  instances,  are  sometimes  acquired 
in  the  course  of  the  acute  infectious  diseases,  and  that,  in  all  probability,  much 
may  be  done  towards  their  prevention  by  a  recognition  of  this  fact. 

Atresia  of  the  vulva  or  the  vagina  may  arise  from  infectious  dis- 
ease at  any  period  of  life,  but  it  is  far  more  frequent  in  childhood.  A  seemingly 
trifling  infection  of  the  genitals  accompanied  by  insignificant  symptoms  may 
lead  to  a  complete  closure  of  the  vagina  or  the  hymen  which  will  remain  unob- 
served until  suspicion  is  excited  by  the  absence  of  menstruation  at  puberty. 
Atresias  are  then  a  class  of  affections  which  is  of  the  utmost  importance  for 
several  reasons.  In  the  first  place  they  have  hitherto  been  comparatively  neg- 
lected by  the  gynecologist,  and  in  the  second,  it  lies  entirely  within  the  province 
of  the  general  practitioner  to  recognize  them  at  their  outset,  which,  as  yet,  has 
hardly  ever  been  done,  and  to  prevent  their  extension  by  the  application  of 
suitable  remedies. 

One  of  the  first  suggestions  as  to  a  causal  relation  between  closure  of  the 
genital  tract  and  infectious  disease  was  made  by  Mossmann  in  1881  (Amer. 
Jour.  Ohst.,  1881,  vol.  14,  p.  564).  Fifteen  years  later  ISTagel  (Zeitschr.  f. 
Geh.  u.  Gyn.,  1896,  vol.  34,  p.  381)  pointed  out  that  it  is  rare  to  find  a 
true  congenital  atresia  of  the  vagina  without  some  arrest  of  development  in  the 
uterus  and  adnexa,  and  stated  that,  in  his  opinion,  most  cases  of  so-called  con- 
genital atresias  of  the  vagina  or  hymen,  where  the  uterus  and  adnexa  are  nor- 
mal, are  acquired.  He  further  held  that  the  majority  of  such  cases  are  the 
result  of  inflammation  of  the  vulva  or  vagina  arising  during  the  course  of 
the  acute  infectious  diseases  in  childhood.  Pincus,  writing  of  primary  amenor- 
rhea in  1903  (Monatsschr.  f.  Geh.  u.  Gyn.,  1903,  vol.  17,  p.  Y51)  laid  stress 
upon  the  fact  that  many  cases  of  retarded  menstruation,  accepted  without  ques- 
tion as  due  to  congenital  obstruction,  are  really  caused  by  atresia  occa- 
sioned by  infectious  disease.  In  confirmation  of  this  opinion  he  points  out  that 
in  four  hundred  and  thirty-nine  cases  of  atresia  of  the  genital  tract  collected  by 

265 


266  ACUTE    INTECTIOTTS    DISEASES    AS    A    CAUSE    OF    PELVIC    DISEASE. 

Xeuo-ebauer  (I.  D.,  Berlin,  1895)  the  proportion  of  acquired  to  congenital  was 
two  to  one  (exclusive  of  cases  arising  after  parturition).  The  following  in- 
structive case  is  cited  by  P  incus : 

A  girl  of  fifteen  had  a  severe  attack  of  scarlatina,  during  which  she 
menstruated  for  the  first  time.  Before  and  after  this  menstruation  she  had  a 
vao'inal  discharge  lasting  three  weeks,  which  at  times  was  stained  with  blood. 
She  became  thin  and  pale,  complaining  of  irritability  of  the  bladder  and  a  feel- 
ing of  uneasiness  in  the  rectum,  with  headache  and  occasional  fever.  Menstrua- 
tion  did  not  return,  and  at  the  end  of  two  months  she  applied  at  the  clinic  for 
relief,  when  examination  showed  that  the  entrance  to  the  vagina  was  closed  by  a 
superficial  membrane  of  a  dark  red  color,  traversed  by  blood  vessels  and  some- 
what excoriated.  On  rectal  examination  the  pelvic  organs  were  found  normal, 
but  a  mass  was  felt  in  the  lower  part  of  the  vagina.  The  superficial  membrane 
was  then  incised  and  about  two  teaspoonfuls  of  a  thick,  purulent  fluid  evacu- 
ated ;  six  days  later  a  vaginal  examination  showed  that  the  hymen  itself  was 
not  closed,  but  completely  covered  by  the  membrane  just  described,  which  was 
easily  stripped  off.  The  atresia  was  in  all  probability  the  effect  of  an  inflam- 
matory process  set  up  by  the  scarlatina,  but  had  the  disease  occurred  a  few 
years  earlier,  the  condition  of  the  genital  organs  by  the  time  puberty  was 
reached  might  have  been  such  as  to  suggest  that  it  was  congenital. 

The  following  cases  of  atresia  of  the  genital  tract,  reported  as  the  effect  of 
infectious  disease  of  various  kinds,  have  been  collected  from  literature,  prin- 
cipally from  ISTeugebauer  {loc.  cit.)  : 

Typhoid  fever. — According  to  Pincus,  typhoid  fever  is  the  most  fre- 
quent cause  of  atresia,  although  the  fact,  he  thinks,  is  little  known.  The  lit- 
erature of  the  subject  bears  out  his  opinion,  and  I  have  collected  nine  cases,  the 
largest  number  associated  with  any  one  disease : 

Boehm  (Busfs  Mag.,  1856,  vol.  46,  Hft.  1). 

L.  Mayer  (Monatsschr.  f.  Geh.  u.  Frauenk.,  1865,  vol.  26,  p.  20). 

Skene  \''  Diseases  of  Women,"  1889,  p.  102). 

Lwoff  {Wratscli,  1893,  ^o.  28). 

Eberlin  (Zeitschr.  f.  Geh.  u.  Gyn.,  1893,  vol.  25,  p.  93). 

Steidele  ("  SammL  von  Beobacht.,"  vol.  2,  p.  24). 

Zweifel  (Centralh.  f.  Gyn.,  1888,  vol  12,  p.  474). 

Small-pox. — The  next  largest  number  of  cases  reported  is  from  small-pox: 

Scanzoni  ("  Traite  des  maladies  des  organes  sexuels  des  femmes,"  1858, 
p.  416). 

Alberts  {Schmidt's  Jalirh.,  1878,  vol.  178,  p.  45). 

Johannovsky  (Arch.  f.  Geh.  u.  Gyn.,  1877,  vol.  11,  p.  371). 

Barthelemy  (Ann.  de  gyn.,  1881,  vol.  2,  p.  23). 

Richter  ("Comment.  Goettingae,"  vol.  2,  Part  II). 

Dysentery  : 

Arnold  (cited  by  Puech,  Gaz.  des  hop.,  1861,  p.  277). 

Przewoski  (cited  by  iSTeugebauer,  loc.  cit.). 


ATRESIA    OF    THE    VULVA    AND    VAGINA.  267 

Pneumonia  : 

Scliultze  (I.  D.,  Jena,  1882). 

Brose  {These  de  Paris,  1896). 

Erysipelas  : 

Bourgeois   (Meissner's  "  Forscliung.,"  vol.  5,  p.   149). 

Cholera  : 

Ebell  (Beiirdg.  f.  Geh.  u.  Gyn.,  1872,  vol.  1,  p.  51). 

Scarlatina  : 

Pincus  (Monatsschr.  f.  Geh.  u.  Gyn.,  1903,  vol.  17,  p.  751)    (two  cases). 

Diphtheria. — It  Avould  seem  that  diphtheria,  with  its  known  tendency  to 
invade  mucous  membranes  in  other  localities  than  the  throat,  would  be  respon- 
sible for  inflammation  of  the  genital  tract  as  often  as  or  oftener  than  other 
infectious  diseases,  but  this  does  not  seem  to  be  the  case.  T  have  found  but  one 
case  in  which  atresia  of  the  vagina  was  reported  as  arising  from  it,  and  that 
was  reported  by  Orth  and  cited  by  ISTeugebauer  (loc.  cit.). 

Measles. — Pincus  states  that,  to  the  best  of  his  belief,  no  case  of  atresia 
of  the  vagina  arising  from  measles  has  been  published.  Two  cases  of  imper- 
forate hymen,  however,  have  been  reported  by  Wuth  (I.  D.  Jena,  1893) 
which  possibly  arose  from  this  cause.  In  both  instances  the  patients,  who  were 
suffering  from  primary  amenorrhea,  had  had  measles  in  childhood,  but  no  other 
infectious  disease;  in  one  case  a  distinct  scar  could  be  traced  along  the  closed 
hymen. 

The  whole  number  of  cases  cited  is  not  so  large  as  might  be  expected,  but 
it  must  be  remembered  that  it  is  only  within  recent  years  that  attention  has 
been  called  to  the  subject,  and  these  cases  have  been  collected  from  papers 
written  to  develop  points  quite  distinct  from  the  question  under  discussion.  I 
have  met  with  fifteen  cases  of  atresia  where  no  mention  is  made  of  causation; 
in  a  few  instances  the  context  implies  that  it  was  considered  congenital,  but 
in  not  one  of  these  cases  is  there  any  mention  of  the  previous  history  of  the 
patient  as  regards  infectious  diseases. 

The  ease  with  which  acquired  atresia  may  be  overlooked  is  shown  in 
the  case  of  Pincus  just  cited,  and  another  case  reported  by  him  shows  the 
importance  of  minute  inquiry  into  the  presence  of  infectious  diseases  in 
childhood. 

A  girl  of  fifteen,  who  had  never  menstruated,  died  in  the  third  week  of 
typhoid  fever  from  peritonitis  induced  by  rupture  of  a  uterine  tube.  Exam- 
ination of  the  external  genitalia,  made  shortly  before  death,  showed  a  fresh 
tear  in  an  otherwise  imperforate  hymen,  which  had  doubtless  occasioned  re- 
tention of  the  menstrual  fluid  with  resulting  hematosalpinx  and  rupture  of  the 
tube.  The  patient's  mother  stated  that  her  daughter  had  an  attack  of  scarlet 
fever  about  four  years  before,  after  which  she  had  a  vaginal  discharge  con- 
taining "  little  fragments  "  (probably  shreds  from  coagulation  or  necrosis). 
This  information  was  obtained  only  by  persistent  inquiry,  and  in  its  absence 
the  case  might  easily  have  been  set  down  as  congenital. 


268  ACUTE    INFECTIOUS    DISEASES    AS    A    CAUSE    OF    PEI.VIC    DISEASE. 

INFLAMMATION    OF    THE    UTERUS    AND    OVARIES. 

In  most  of  the  text-books  on  gynecology,  I  find  the  "  eruptive  fevers/'  the 
"  acute  exanthemata,"  or  the  "  acute  infectious  diseases  "  mentioned  in  the  list 
of  specified  causes  of  ovaritis  and  endometritis,  hut  in  none  which  I  have  seen 
is  there  any  more  particular  mention  of  the  subject,  with  one  exception,  namely, 
"  A  Text-hook  on  Diseases  of  AVomen,"  by  C.  B.  Penrose,  1001,  pp.  197,  330. 
Periodical  literature  is  little  more  satisfactory,  for  of  the  papers  scattered  here 
and  there  at  wdde  intervals,  only  two  are  important. 

Ovaries. — Lawson  Tait  (''Diseases  of  the  Ovaries,"  1883,  p.  100)  called 
attention  in  1874  to  the  occurrence  of  pelvic  peritonitis  after  attacks  of  scarla- 
tina or  small-pox,  stating  that  he  had  observed  a  number  of  cases  of  the  kind  in 
question  during  an  outbreak  of  small-pox  at  Birmingham.  Tait  was  of  opinion 
that  there  was  a  special  variety  of  inflammation  of  the  ovaries 
associated  with  certain  of  the  exanthemata  which  might  or  might 
not  be  followed  by  general  atrophy  of  the  organs,  and  some  years  later  he  pub- 
lished a  case  of  superinvolution  of  the  uterus  which  he  believed  to  be  of  this 
kind. 

After  the  publication  of  Tait's  opinion  the  possibility  of  a  special  form  of 
inflammation  of  the  genital  organs  associated  with  infectious  diseases  was  occa- 
sionally discussed,  but  only  two  of  the  contributions  to  the  subject  are  based 
upon  scientific  evidence. 

The  first  of  these  papers,  by  Lebedinsky  (Abst.  in  Centrhl.  f.  Gyn.,  1877,. 
vol.  1,  p.  110)  treats  of  the  changes  observed  in  the  ovaries  after  death  from 
scarlatina.  The  macroscopical  appearances  were  found  to  be  unaltered,  but 
microscopical  examination  showed  that  the  Graafian  follicles  were  in  a  state  of 
parenchymatous  inflammation,  varying  in  degree  from  a  slight  cloudy  swelling 
to  complete  destruction  of  the  epithelium.  The  younger  the  follicle  the  more 
severe  the  changes.  The  stroma  of  the  ovary  was  not  affected  except  from 
hyperemia  of  some  of  the  solitary  follicles  in  the  connective  tissue.  The  great- 
est changes  were  found  in  the  ovaries  of  a  child  eight  years  old,  who  had 
measles  three  weeks  after  recovery  from  scarlet  fever,  and  died  after  an  illness 
of  eight  days.  Here  the  greater  part  of  the  follicles  was  filled  with  a  finely 
granular  structureless  mass,  and  the  greater  part  of  the  cortical  layer  of  the 
follicles  had  altogether  disappeared.  Scar  tissue  was  present  at  all  stages  of 
the  inflammatory  process.  Lebedinsky  considered  that  the  changes  in  the 
ovary  were  similar  to  those  taking  place  in  other  parenchyma- 
tous organs  during  scarlatina,  and  believed  that  the  degeneration 
of  such  a  number  of  follicles  results  in  more  or  less  impair- 
ment of  the  function,  sufficient  in  some  cases  to  affect  the 
reproductive    capacity. 

The  second  article  is  by  Skrobansky  (Jour,  d'ohst.  et  de  gyn.,  Oct.,  1901) 
and  contains  the  results  of  investigations  into  the  condition  of  twenty-seven 
ovaries  belonging  to  women  and  cliildren  dying  of   scarlatina,    diphtheria. 


INFLAMMATION    OF    THE    UTERUS    AND    OVARIES.  269 

typlioid  fever,  and  miliary  tuberculosis.  In  all  cases  the  ovaries  had 
undergone  more  or  less  degeneration,  but  its  character  was  the  same, 
no  matter  what  was  the  form  of  infection.  Furthermore,  neither 
the  intensity  nor  the  duration  of  the  disease  made  any  difference  in  the  extent 
of  the  affection.  In  some  instances  where  the  disease  was  most  virulent,  the 
changes  in  the  ovaries  were  of  the  slightest,  while  in  others,  where  the  disease 
was  much  lighter  in  intensity,  the  ovaries  were  considerably  affected.  From 
these  facts  Skrobansky  and  Lebedinsky  draw  the  same  conclusions,  namely, 
that  the  changes  caused  by  infectious  diseases  upon  the  ovaries 
are  exactly  the  same  as  those  produced  by  them  upon  other 
parenchymatous   organs. 

Since  the  appearance  of  the  second  of  these  papers,  a  case  of  abscess  of 
the  ovary  during  typhoid  fever  has  been  reported  by  B.  C.  Plirst  (/ow?\ 
Amer.  Med.  Assoc,  Feb.  11,  1905),  and  another  in  which  the  uterine  ap- 
pendages were  inflamed  during  the  same  disease  by  E.  Dirmoser 
(Centrhl.  f.  Gyn.,  1904,  voL  28,  p.  117Y).' 

Uterus. — The  changes  wrought  by  infectious  diseases  upon  the  uterus  were 
investigated  by  Massin  {Arch.  f.  Oeh.  u.  Gyn.,  1891,  vol.  40,  p.  146),  and 
I  believe  his  conclusions  have  not  been  contradicted.  He  gives  a  brief  review 
of  the  literature  and  shows  that  up  to  the  time  he  wrote,  opinions  upon  the 
subject  were  so  contradictory  that  it  might  be  considered  an  open  question.  He 
examined  the  changes  in  the  uterus,  both  gross  and  microscopical,  in  eighteen 
cases,  two  of  which  had  died  of  croupous  pneumonia,  three  of  typhoid, 
one  of  dysentery,  and  twelve  of  ''relapsing  fever."  In  all  of  them 
he  found  definite  inflammatory  changes  in  the  endometrium, 
accompanied,  in  many  instances,  by  hemorrhage  leading  to  a 
typical  hemorrhagic  condition.  The  inflammatory  changes  were  the 
same  as  those  observed  under  ordinary  circumstances,  but  they  varied  in  in- 
tensity with  the  disease,  as  in  all  cases  where  the  temperature  was  persistently 
high  there  was  hemorrhage,  while  it  was  present  in  only  half  the  number  of  the 
milder  cases.  The  substance  of  the  uterus  was  little,  if  at  all  affected,  although 
in  a  few  cases  the  changes  appeared  to  extend  out  from  the  endometrium. 
Massin  concluded,  therefore,  that  the  acute  infectious  diseases  must 
be  regarded  as  one  of  the  causes  of  uterine  disease  in  women, 
and  especially,  he  says,  in  those  cases  where  the  disease  occurs 
before    puberty. 

The  question  whether  the  endometrium  is  liable  to  be  affected  during  gonor- 
rheal vaginitis  in  little  girls  has  been  recently  investigated  by  Jung  (Centrhl. 
f.  Gyn.,  1904,  vol.  28,  p.  991).  He  examined  nine  children  between  the  ages 
of  two  and  nine,  in  whom  the  gonococcus  was  known  to  be  present  in  either 
the  vagina  or  the  urethra  when  the  child  entered  the  hospital.  The  examina- 
tions were  repeated  every  eight  days  in  order  to  ascertain  whether  the  gonococ- 
cus was  still  present  in  the  cervical  secretion,  and  were  kept  up  for  three  or 
four  months.     Jung  came  to  the  conclusion  that  infection  of  the  cervical 


270  ACUTE    IXFECTIOIJS    DISEASES    AS    A    CArSE    OF    PEEVIC    DISEASE. 

secretion  Ity  the  aouococcns,  altliougli  it  iiii<l<nil(tedly  occurs, 
is  of  extreme  rarity. 

From  these  three  articles,  therefore,  Lehedinsky's,  Skrobausky's,  and  Mas- 
sin's,  it  seems  that  disease  of  the  uterus  or  ovaries  may  have  a  starting  point 
in  the  acute  infectious  diseases,  but  that  the  inflammatory  changes  excited  by 
these  aftections  are  not  in  any  way  different  from  those  which  they  cause  in 
other  organs.  It  seems  probable  that  the  pelvic  organs  are  more  or  less  affected 
in  almost  all  cases  of  infectious  disease,  but  if  the  changes  are  slight  they  will 
pass  away  with  recovery,  like  other  changes  incidental  to  the  disease ;  on  tlie 
other  hand,  should  there  be  disturbances  of  a  serious  character,  the  foundation 
for  future  disease  of  a  subacute  or  chronic  nature  will  be  laid. 

The  whole  question  is  clearly  stated  by  Penrose  (Joe.  cit.).  "Acute 
rhemnatism,"'  he  says,  "  and  the  eruptive  fevers  may  produce  oophoritis.  The 
disease  of  the  ovary  is  often  overlooked  during  the  acute  attack  while  the  atten- 
tion of  the  physician  is  engaged  with  the  general  affection.  These  diseases, 
occurring  in  childhood,  are  the  probable  cause  of  some  of  the  damaged  and 
chronically  inflamed  ovaries  with  whick  women  suffer  in  later  life.  To  these 
diseases  are  also  to  be  attributed  many  cases  of  arrested  development  of  the 
sexual  organs,  the  phenomena  of  which  appear  only  after  menstruation  has 
begun.  The  ovarian  disease  in  these  cases  may  be  insidious.  Decided  micro- 
scopical changes  have  been  found  in  the  ovarian  follicles  in  scarlet  fever,  though 
to  the  naked  eye  the  gland  was  unchanged."  Again  he  says :  "  Acute  inflam- 
mation of  the  endometrium  sometimes  occurs  during  the  exanthemata.  The 
changes  which  take  place  in  the  mucous  membrane  are  similar  to  those  seen 
in  other  mucous  membranes  during  the  course  of  the  disease.  The  local  con- 
dition is  usually  limited  by  the  duration  of  the  general  disease.  It  is  prob- 
able that  some  of  the  cases  of  arrested  development  in  the  internal  organs  of 
generation  as  well  as  cases  of  chronic  tubal  disease  and  ovarian  disease  seen 
during  later  life  may  be  traced  to  this  exanthematous  form  of  endometritis 
occurring  during  girlhood."' 

The  fact  that  the  acute  infectious  diseases  are  the  exciting  cause  of  many 
cases  of  pelvic  disease  places  the  responsibility  for  their  causation  prominently 
upon  the  shoulders  of  the  general  practitioner.  As  Penrose  says,  the  symptoms 
indicating  the  extension  of  the  original  disease  to  the  pelvic  organs  mav  easilv 
be  overlooked  while  the  physician  is  occupied  with  the  general  symptoms,  espe- 
cially as,  in  the  case  of  the  ovaries  at  least,  there  is  no  relation  between  the 
virulence  of  the  disease  and  the  extent  of  local  changes.  It  is  of  the  great- 
est importance  that  the  physician  should  never  lose  sight  of 
the  fact  that  the  pelvic  organs,  the  vulva,  and  the  vagina  may  be 
affected,  nor  allow  the  slightest  indication  of  the  fact  to  escape 
him.  Under  any  circumstances  a  case  presenting  symptoms  of  vaginal  dis- 
turbance should  be  carefully  watched  for  some  time  after  recovery,  and  in  the 
case  of  little  girls  it  is  well  to  warn  their  parents  that  they  should  be  under 
professional  observation  during  the  establishment  of  the  menstrual  function. 


MALARIA    AND    DISEASE    OF    THE    PELVIC    OECrANS.  271 

It  may  not  be  amiss  to  call  attention  here  to  the  frequency  with  which 
menorrhagia  or  metrorrhagia  accompanies  infectious  disease. 
The  fact  that  the  endometrium  is  so  constantly  affected  makes  it  not  unreason- 
able to  suppose  that  the  uterine  hemorrhage,  hitherto  attributed  to  constitutional 
causes,  may  be  a  direct  effect  of  the  inffammatory  condition  of  the  uterus,  and 
therefore  a  danger  signal  to  the  physician.  If  there  is  any  purulent  or  bloody 
discharge  or  other  evidence  of  a  grave  inflammatory  or  sloughing  process  going 
on,  it  will  be  best  to  irrigate  the  vagina  at  least  once  a  day,  using  a  glass 
catheter  as  a  douche  nozzle  and  washing  it  out  with  a  two  per  cent  solution  of 
carbolic  acid  or  a  one  per  cent  solution  of  permanganate  of  potash 
in  hot  water  until  the  discharge  ceases. 

MALARIA    AND    DISEASE    OF    THE    PELVIC    ORGANS. 

The  relation  between  malaria  and  disease  of  the  pelvic  organs  has  been  in- 
vestigated by  Lemanski,  who  published  a  book  on  the  subject  in  1889.  Leman- 
ski,  who  practised  medicine  in  Tunis  for  six  years,  had  ample  opportunity 
for  observing  the  effects  of  malaria  upon  the  various  affections  of  the  repro- 
ductive organs.  The  following  conclusions  are  taken  from  a  copious  review 
of  his  book  in  the  Revue  prac.  d' ohstetrique  et  de  gynecologie,  1899,  vol.  15, 
p.  39: 

The  malarial  cachexia  is  a  common  etiological  factor  in  the 
genital  affections  of  women  living  in  climates  where  it  pre- 
vails. According  to  Lemanski's  observations,  cases  of  endometritis  and 
metritis  in  malarial  districts  defy  all  forms  of  treatment,  even  curettage,  until 
a  course  of  specific  treatment  for  malaria  is  instituted ;  it  should  be  added, 
however,  that  even  in  cases  where  malaria  is  known  to  be  a  causal  factor, 
curettage  is  often  necessary  to  effect  a  cure,  in  association  with  the  specific 
treatment. 

Menstruation  is  often  noticeably  affected  by  the  malarial  cachexia  even 
in  the  absence  of  any  organic  lesion.  In  some  cases  it  is  profuse  and  over 
frequent  ;  in  others  complete  amenorrhea  exists  from  the  beginning  of  the 
malarial  infection.  In  a  few  cases  there  is  metrorrhagia  and  the  inter- 
menstrual hemorrhages  may  show  a  periodicity  resembling  that  of  malaria  and 
disappearing  under  the  influence  of  quinine. 

Pregnancy  is  often  unfavorably  affected  by  malaria.  Labor  is  difficult 
and  abortions  of  frequent  occurrence,  especially  in  the  pernicious  form. 
Eclampsia,  on  the  other  hand,  is  not  common.  The  puerperium  is  apt 
to  be  accompanied  by  a  rise  of  temperature,  even  in  the  absence  of  all  local 
infection,  but  the  elevation  is  not  continuous.  If  the  temperature  is  taken  every 
hour,  or  two  hours,  throughout  the  day  it  will  be  found  to  be  normal  at  some 
periods  and  slightly  elevated  at  others.  The  special  time  of  the  day  associated 
with  the  elevation  is  not  mentioned. 

The  treatment  of  such  cases  is    quinine,    which  in  pressing  cases  must  be 


272  ACUTE    INFECTIOUS    DISEASES    AS    A    CAUSE    OF    PELVIC    DISEASE. 

given  hypodeniucally.  Arsenic  is  higbly  recomnieuded,  and  Lenianski  ad- 
vises giving  it  in  tlic  form  of  a  rectal  enema,  containing  half  a  centigTamme 
(about  one-fifteenth  of  a  gTain)  of  arsenions  acid  in  twenty-fonr  hours,  or  if 
it  is  preferred  an  equal  qnantity  of  arseniate  of  soda. 

I  may  add  that  it  is  most  desirable  for  all  physicians  practising  in  malarious 
districts  to  bear  in  mind  the  influences  which  the  infection  may  bear  upon 
gynecological  affections  under  their  care.  .The  existence  of  a  malarial  influence 
is  easily  settled  by  an  examination  of  the  blood.  Dr.  Lemanski  considers  it 
especially  important  to  remember  that  there  may  be  a  complete  ab- 
sence   of   all   symptoms    commonly    associated    with   malaria. 

H.  C.  Coe  has  reported  an  interesting  case  (Amer.  Jour.  Med.  Sci.,  1891, 
vol.  101,  p.  365)  in  which  the  patient,  a  married  woman  about  twenty  years  of 
age,  had  an  attack  of  violent  pain  in  the  region  of  the  right  ovary  accompany- 
ing menstruation  and  continuing  after  it  had  ceased.  After  the  pain  had  lasted 
several  days,  in  spite  of  all  measures  for  its  relief,  it  was  noticed  that  it  became 
severe  every  afternoon,  reached  its  acme  during  the  night,  and  then  subsided  by 
morning,  though  it  never  disappeared  entirely.  On  inquiry  it  appeared  that 
the  patient  had  had  a  well-marked  attack  of  intermittent  fever  of  the  quotidian 
type  a  few  months  before,  in  which  the  chill  had  occurred  in  the  afternoon. 
Acting  upon  the  assumption  that  the  pain  might  be  malarial  in  its  nature,  large 
doses  of  quinine  were  given  each  morning  for  several  successive  days  with  com- 
plete relief  of  suffering.  The  pain  in  this  instance  was  undoubtedly  associated 
with  ovarian  congestion,  for  the  patient  had  had  inflammatory  trouble  of  the 
right  ovary  a  year  or  two  before,  but,  as  Coe  suggests,  it  seems  possible  to  regard 
it  as  one  of  malarial  neuralgia  affecting  the  nerves  around  the  ovary  and  com- 
parable to  similar  neuralgia  in  the  trifacial.  The  periodicity  of  the  suffering 
he  ascribed  to  the  malarial  element. 

METASTASES    TO   THE    SEXUAL    ORGANS    DURING    PAROTITIS. 

It  is  well  kno^vn  that  parotitis  in  boys  and  men  is  sometimes  complicated 
with  orchitis,  supposed  to  arise  from  metastasis,  but  there  has  been  a  difference 
of  opinion  as  to  whether  the  ovaries  are  ever  affected  in  a  similar  manner. 
Within  the  last  few  years,  however,  two  intelligent  articles  upon  the  subject 
have  appeared  which  would  seem  to  answer  the  question  in  the  affirmative. 

One  of  these  papers,  which  appeared  in  1902,  is  by  a  Russian,  Troitski; 
it  is  based  upon  observations  made  during  an  epidemic  of  parotitis  in  young 
girls,  where  the  ovaries  were  affected  in  a  number  of  cases  (Russkoi  Vratcli, 
1902,  vol.  1,  p.  582).  The  other  article,  which  appeared  the  following  year, 
is  by  G.  MclSTaughton ;  it  contains  one  case  under  personal  observation,  and 
gives  an  excellent  review  of  literature  on  t-he  subject,  together  with  a  translation 
of  the  main  points  of  the  Russian  article  (BrooM.  Med.  Jour.,  1903,  vol.  17, 
P-  115).  .    ^        ^ 

The  epidemic  observed  by  Troitski  lasted  thirty-five   days,   and   covered 


METASTASES    TO    THE    SEXUAL    ORGANS    DURING    PAROTITIS.  273 

thirty-three  cases.  The  ages  of  the  patients  varied  from  nine  to  fifteen  years, 
the  majority  being  between  twelve  and  fourteen.  Of  the  whole  number  of 
patients  the  ovaries  were  affected  in  thirteen,  eight  of  whom  had  menstruated. 
It  was  noticeable  that  when  both  parotids  were  affected,  the  ovaries  on  both 
sides  were  swollen  and  tender ;  while  when  only  one  parotid  was  inflamed,  the 
ovarv  on  the  same  side  alone  was  attacked.  The  tenderness  and  swelling  in 
the  ovary  lasted,  as  a  rule,  longer  than  in  the  parotid ;  in  no  case  was  there 
any  sign  of  abscess  formation.  As  no  vaginal  examination  was  made,  there  is 
no  certainty  of  diagnosis,  but  the  tenderness  and  swelling  in  the  ovarian  region 
were  so  marked  as  to  be  typical.  The  mammary  glands  were  never  affected. 
Considerable  pains  were  taken  to  ascertain  whether  the  attacks  were  followed  by 
any  disturbances  of  menstruation,  but  in  every  case  the  answer  was  negative. 

Mc^aughton  gives  a  number  of  cases  collected  from  literature  as  well  as 
his  own,  which  was  that  of  a  young  girl,  eighteen  years  old,  who  had  double 
parotitis ;  on  the  fifth  day,  when  the  swelling  was  beginning  to  subside,  she 
was  attacked  by  pain  in  both  ovarian  regions,  which  increased  in  severity  for 
two  days,  becoming  at  last  so  intense  as  to  require  opium  for  its  relief.  At 
the  end  of  the  two  days  a  bloody  discharge  appeared  from  the  vagina  and  the 
other  symptoms  subsided.  ]^o  mention  is  made  of  swelling  or  tenderness. 
The  patient  had  menstruated  regularly  for  four  years,  and  her  last  period 
had  been  eleven  days  before  the  mumps  appeared.  She  did  not  menstruate 
again  for  nearly  six  weeks  (unless  the  bloody  discharge  during  the  parotitis 
is  regarded  as  menstrual),  making  the  interval  between  the  two  periods  nearly 
two  months  in  all. 

Thirteen  cases  are  given  by  Troitski ;  MclS^aughton  gives  fifteen  taken  from 
literature,  besides  one  of  his  own;  to  these  I  can  add  three,  making  a  total  of 
thirty-two,  some  of  which,  at  least,  were  observed  with  the  utmost  care  and 
intelligence,  and  they  would  seem  to  leave  no  doubt  that  the  ovaries  are 
sometimes  affected  in  parotitis,  although,  as  MclSTaughton  says,  it  is 
perhaps  going  too  far  to  assume  that  the  ovaries  alone  are  definitely  affected, 
for,  in  the  absence  of  any  vaginal  examination,  it  is  impossible  to  exclude  other 
pelvic  inflammations  or  engorgements,  especially  as  no  opportunity  for  autopsies 
in  such  cases  is  ever  afforded.  The  complication  is  probably  a  rare  one,  though 
not  so  rare  as  has  been  assumed,  and  if  the  cases  which  do  occur  were  brought 
under  the  attention  of  the  profession  we  might  find  it  more  common  than  we 
now  suppose. 

Swelling  of  the  mammary  glands  and  of  the  labia  have  been  re- 
ported as  occurring  during  mumps,  and  MclSTaughton  gives  a  case  of  each,  taken 
from  the  literature,  as  well  as  two  cases  of  abortion,  occurring  during  the 
progress  of  a  parotitis  and  attributed  to  its  influence. 

The  relation  between  the  parotid  gland  and  the  sexual  organs  is  illustrated 
by  a  unique  case  reported  by  A.  Harkin  (Lancet,  1886,  vol.  1,  p.  374)  of  a 
woman  who  had  an  enlargement  of  the  left  parotid  during  six  successive  preg- 
nancies and  at  no  other  time.  The  swelling  appeared  soon  after  the  beginning 
19 


2^4  ACUTE    INFECTIOUS    DISEASES    AS    A    CAUSE    OF    PELVIC    DISEASE. 

of  pregnancy  and  continued  to  increase  nntil  it  reached  the  size  of  an  orange. 
It  lasted  nntil  pregnancy  was  over,  beginning  to  disappear  as  soon  as  labor  was 
finished  and  disappearing  entirely  by  the  end  of  a  month,  except  for  a  slight 
permanent  enlargement  which  persisted  after  the  first  attack.  There  was  no 
redness  nor  tendency  to  suppuration,  nor  were  there  any  of  the  usual  symptoms 
of  preg-nancy,  such  as  morning  sickness  or  increased  salivation. 


CHAPTEK    XI. 
VULVITIS.    VAGINITIS.    CERVICITIS.    ENDOMETRITIS. 

(1)  General  considerations,  p.  275. 

(2)  Vulvitis:  Symptoms,  p.  276.     Treatment,  p.  276. 

(3)  Vaginitis:  Varieties  and  symptoms,  p.  280.     Treatment,  p.  282. 

(4)  Cervicitis:  Symptoms,  p.  287.     Treatment,  p.  288. 

(5)«  Endometritis:  Rarity,  p.  291.     Varieties  and  symptoms,  p.  293.     Treatment,  p.  294.     Senile 
endometritis,  p.  294. 

A  CATALOGUE  of  tlie  inflammatory  affections  of  the  genital  tract  from  the 
vulva  up  to  the  pelvic  peritoneum  would  serve  to  show  the  various  anatomical 
structures  in  which  an  inflammatory  affection,  especially  a  gonorrheal  infection, 
is  prone  to  lodge.     The  organs  and  parts  thus  affected  are : 

The  vulva. 

Bartholin's  glands. 

Skene's  glands  (urethral  glands). 

The  vagina. 

The  cervix  uteri. 

The  endometrium. 

The  uterine  tubes. 

The  ovarian  follicles. 

The  pelvic  peritoneum. 

Vulvitis  is  a  comparatively  rare  affection,  seen  oftenest  in  young  per- 
sons with  tender  epithelia,  easily  attacked  by  micro-organisms,  especially  the 
gonococcus.  The  adult  vagina,  with  its  stratified  epithelium,  long  resists 
the  lodgment  of  an  infection,  but  when  once  infected,  it  is  slow  to  recover 
spontaneously.  A  vaginal  infection  is  not,  as  a  rule,  of  a  gonorrheal  character, 
except  in  the  young,  when  it  is  transitory,  owing  to  the  readiness  with  which 
the  vagina  purges  itself  of  its  secretions  and  also  to  the  fact  that  there  are  no 
crypts  or  glands  to  lodge  an  infection.  The  cervical  canal,  with  its  deep 
glands  secreting  a  mucilaginous  fluid,  forms  the  readiest  place  for  the  lodg- 
ment of  an  infection,  especially  of  a  gonorrheal  character,  in  the  entire  genital 
tract;  once  entered  here,  the  pathogenic  organisms  are  exceedingly  difiicult  to 
dislodge.  The  endometrium,  on  the  other  hand,  in  spite  of  the  fact  that 
anatomically  it  would  seem  to  form  a  most  favorable  nidus,  is  rarely  found 
infected  with  a  chronic  disease,  outside  of  the  puerperal  period.  This  is  prob- 
ably due  to  the  monthly  purging  of  this  membrane.  The  uterine  tubes, 
when  slightly  inflamed,  quickly  become  closed  in  the  portion  which  traverses 

275 


276  VTLVITIS.       VAGINITIS.       CERVICITIS.       ENDOMETEITIS. 

the  uterine  cornua ;  in  like  manner  the  fimbriated  end  soon  becomes  aggluti- 
nated to  the  adjacent  peritoneum  and  inverted  on  itself.  In  this  way  the 
tubes  are  converted  into  closed  sacs  or  almost  closed  sacs,  discharging  the  pus 
with  difficulty,  if  at  all,  and  thus  serving  to  lodge  an  infection  for  years.  The 
ovary  is  not  a  common  nidus;  in  occasional  cases,  however,  an  infection, 
particularly  the  gonococcus,  enters  the  ruptured  follicles  and  converts  the  ovary 
into  a  thick-walled  abscess.  Abscesses  of  the  peritoneum  outside  of 
the  tubes  and  ovaries  are  rare. 

VULVITIS. 

Symptoms. — The  initial  inflammation  of  a  gonorrheal  vulvitis  soon  subsides, 
but  the  affection  may  creep  into  the  vulvo-vaginal  glands  on  either  side 
and  linger  in  the  gland  itself  (Bartholinitis)  or  in  the  duct,  indefinitely.  An 
acute  vulvitis  with  free  discharge  and  with  swelling  is  practically  always  gon- 
orrheal. A  form  of  vulvitis  is  sometimes  seen  in  children,  due  to  utter  neglect 
of  cleanliness,  which  is  of  a  decidedly  milder  character  than  the  specific  form. 
Chronic  eczematous  conditions,  often  affecting  the  skin  as  well  as  the  mucous 
surfaces,  must  be  distinguished  from  a  true  vulvitis.  These  are  apt  to  be 
localized  and  accompanied  by  great  thickening  as  well  as  the  shedding  of  epi- 
thelial debris.  The  patients,  too,  are  older  women  (see  Chap.  XII).  Again, 
the  little  urethral  glands  (Skene's  glands)  may  lodge  a  drop  or  two  of 
pus  containing .  the  infecting  organism  and  so  form  a  nidus  for  reinfection 
persisting  for  years.  A  gonorrheal  vulvitis,  like  a  gonorrheal  vaginitis  or 
salpingitis,  is  only  to  be  recognized  with  certainty  by  a  microscopic  examina- 
tion of  a  smear  made  on  a  slide.  If  the  physician  has  not  the  requisite  train- 
ing he  must  send  the  specimen  to  some  competent  authority.  An  ordinary 
darning  needle  is  heated  red-hot  at  the  eye  end  and  allowed  to  cool;  then  a 
little  of  the  secretion  is  taken  up  and  smeared  as  thin  as  possible  on  a  clean 
glass  slide.  This  can  be  protected  by  putting  another  slide  on  top  of  it  and 
sent  by  mail  to  the  nearest  pathologist  for  an  opinion. 

The  best  places  from  which  to  get  the  pus  are  the  orifices  of  Bartholin's 
glands,  the  orifice  of  the  urethra,  or  the  cervix. 

Treatment. — Acute  vulvitis,  which  is  practically  the  only  form  ever  seen,  is 
best  treated  by  frequent  bathing  and  cleansing  of  the  parts;  by 
vaginal  douches  which  wash  away  the  secretions  pouring  out  of  the  vagina 
over  the  vulva;  and  by  the  application  of  solutions,  such  as  the  familiar 
lead-water  and  laudanum,   or  a  saturated  solution  of  boric  acid. 

When  the  disease  lodges  in  one  of  the  vulvo-vaginal  glands  (Bartho- 
lin's glands),  one  of  several  things  is  apt  to  take  place.  If  the  duct  is  affected 
and  occluded,  the  gland  swells  up,  so  as  to  form  a  unilateral  swelling,  containing 
a  clear  sterile  fluid  (Bartholin's  cyst),  and  causes  the  vulvar  mucosa  of  one  side 
to  bulge  out  over  the  vaginal  opening  in  the  form  of  a  mass  the  size  of  a  pigeon's 
egg.  If  the  gland  itself  is  involved  in  the  infection  it  becomes  converted  into 
a  large  tender  abscess  (see  Tig.  75)  which  may  rupture  spontaneously.     With 


TREATMENT    OF    VULVITIS. 


277 


the  disappearance  of  the  abscess,  the  gland  itself  may  remain  behind  in  a  state 
of  chronic  inflammation,  as  a  tender  hard  nodule,  about  the  size  and  shape  of 
a  lima  bean. 

The   treatment   of  the   simple  cysts   of  Bartholin's   gland   is  by 
excision.     It  is  not  necessary  to  give  the  patient  a  general  anesthetic  to  do  this 


Fig.  75. — Abscess  of  Left  Bartholin's  Gland,  due  to  a  Gonorrheal  Infection  Traveling  down 
THE  Duct.     The  treatment  in  such  a  case  is  free  incision  and  drainage. 

operation;  a  little  freezing  mixture,  such  as  chloride  of  ethyl,  sprayed  on 
the  part  is  sufficient,  and  then  at  the  little  frozen  area  a  hypodermic  needle  is 
inserted  and  a  weak  solution  of  cocain  and  morphin  injected.  Schleich's 
solution    (medium  strength)  is  made  after  the  following  formula: 

1^   Morph.  sulph gr-  ro 

Cocain  hydrochl gr.  ^ 

Saline  sol.  y  o"  P-  ^ f Bj 

M.     S.  Use  as  a  hypodermic  injection. 

After  the  tissues  overlying  the  gland  have  been  injected,  it  may  be  incised 
on  its  most  prominent  part ;  the  fluid  then  escapes  and  the  white  walls  of  the 
gland  are  seen.  These  are  grasped  with  forceps  and  gradually  dissected  free 
from  the  underlying  tissues.  The  bleeding  from  this  operation  is  sometimes 
free,  though  never  dangerous.     The  operator  must  be  prepared  to  pass  several 


278  VULVITIS.       VAGIiSriTIS.        CEEVICITIS.       EjSTDOMETEITIS. 

sutures  from  side  to  side  after  the  extirpation  of  the  lining  membrane  of  the 
cyst,  to  close  the  wound.  It  is  sometimes  permissible  simply  to  split  the  sac 
widely  open  and  remove  a  large  oval  piece  from  the  anterior  wall,  after  which 
the  sac  is  packed  and  allowed  to  close  by  granulation.  This  is  not  so  good 
practice,  however,  as  the  extirpation,  which  takes  a  little  more  time  and  trouble. 
When  the  gland  has  become  converted  into  an  abscess,  a  somewhat  similar  plan 
of  treatment  may  be  adopted.  The  overlying  tissues  are  frozen,  and  the  abscess 
is  then  opened  from  top  to  bottom  with  a  sharp  knife,  or  with  a  knife  followed 
by  a  pair  of  scissors,  after  which  the  cavity  is  packed  with  an  iodoform  gauze 
pack  and  allowed  to  granulate  up  from  the  bottom.  It  is  a  good  plan  to  apply 
a  saturated  solution  of  carbolic  acid  on  a  little  pledget  of  cotton  to  the  whole 
interior  of  the  sac.  This  generally  wipes  the  infecting  organisms  out  of  exist- 
ence and  leaves  a  wound  which  heals  much  more  rapidly. 

When  there  is  a  chronic  infection  of  the  gland,  sometimes  with  a  fistula,  the 
only  right  method  of  treatment  is  to  anesthetize  the  patient  and,  after  properly 
cleansing  the  parts,  to  cut  down  on  the  gland  over  its  most  prominent  part,  and 
extirpate  it  entirely,  avoiding,  if  possible,  any  contamination  of  the  wound. 
The  operation  may  for  a  time  be  rather  bloody,  but  the  bleeding  structures 
are  readily  seen  and  caught  with  forceps,  and  the  hemorrhage  is  easily  controlled 
by  passing  the  catgut  sutures,  used  to  close  the  wound,  deep  enough  to  include 
and  make  firm  pressure  on  the  bleeding  tissues. 

The  urethral  glands  (Skene's)  when  infected  sometimes  cause  a  de- 
cided pouting  of  the  lower  part  of  the  urethra,  and  if  one  side  only  is  involved, 
the  gland  may  project  out  and  displace  the  orifice  of  the  urethra  towards  the 
opposite  side  of  the  body,  or  even  convert  it  into  a  semi-lunar  slit.  By  pressing 
the  urethral  orifice  up  under  the  pubic  arch  and  squeezing  a  little  from  above 
downwards  with  the  index  finger,  an  infected  urethral  gland  may  be  emptied 
of  one  or  two  drops  of  thick,  yellow  pus. 

The  best  treatment  for  such  a  case  is  to  use  either  cocain  injections  or  a 
general  anesthetic  (nitrous  oxide  is  the  best  here)  and  then  lay  the  gland 
freely  open  with  a  small  knife.  After  opening,  it  may  be  curetted  or 
burned  out  with  carbolic  acid.  It  should  be  left  open  to  granulate  up  from 
the  bottom.  Palliative  treatments  in  the  form  of  irrigations  through  the 
opening  of  the  gland  are  readily  carried  out,  but  they  bring  about  an  improve- 
ment very  slowly. 

Suburethral  Abscess. — This  condition  sometimes  resembles  an  enlarge- 
ment of  the  peri-urethral  (Skene's)  glands,  but  must  not  be  mistaken  for 
it.  A  suburethral  abscess  is  a  cushiony  eminence  or  pouch,  formed 
by  a  diverticulum  from  the  urethra,  which  contains  from  half  a  drachm  to  a 
drachm  of  pus.  The  abscess  is  due  to  an  infection  of  one  of  the  urethral  glands, 
and  forms  a  tumor  which  sometimes  becomes  as  large  as  the  last  joint  of  the 
thumb.  It  is  apt  to  cause  a  good  deal  of  pain  with  occasional  discharges  of 
pus,  and  it  also  gives  rise  to  a  pyuria  which  may  be  puzzling  until  the  local 
examination  is  made.     Even  when  the  patient  is  examined,  it  is  easy  to  over- 


TREATMENT    OF    SUBUKETHKAL    ABSCESS.  279 

look  a  suburethral  abscess,  as  it  closely  resembles  a  simple  urethro- 
cele,  or  a  displacement  downwards  of  the  urethra  itself.  The 
diagnosis  will  not,  however,  escape  an  attentive  observer  who  makes  pressure 
on  the  prominence,  which  is  often  painful,  and  discovers  the  escape  of  pus  by 
the  urethral  orifice.  On  introducing  a  catheter,  the  instrument  may  enter  the 
bladder  and  draw  clear  urine,  and  then  be  carried  into  the  pocket  on  the  floor 
of  the  urethra  and  draw  off  pure  pus.  The  treatment  of  such  an  abscess 
may  be  by  a  simple  incision  of  the  anterior  vaginal  wall,  followed  by  drainage. 
This  is  often  sufficient  to  cure  the  case.  A  more  complete  operation,  and  one 
more  agreeable  to  the  surgeon,  is  the  oval  excision  of  a  piece  of  the  anterior 
vaginal  wall  overlying  the  tumor,  followed  by  the  extirpation  of  the  inner  mem- 
brane of  the  abscess  down  to  its  urethral  opening.  The  wound  is  then  closed 
by  interrupted  sutures  from  side  to  side,  after  which  the  patient  is  entirely 
relieved. 


280  VIJLVITIS.       VAGINITIS.        CEEVICITIS.       ENDOMETEITIS. 


VAGINITIS. 

Inflammation  of  tlie  vagina  is  most  commonly  seen  at  the  extremes  of  life ; 
it  is  not  so  common  in  the  middle-aged  woman  whose  resisting  powers  are 
gi'cater,  although  often  seen  in  prostitutes.  There  are  several  forms  of  the 
disease,  according  to  the  organism  provoking  the  inflammation.  Vaginitis 
may  also  he  divided  according  to  the  condition  of  the  tissues  and  the  distribu- 
tion of  the  disease.     A  further  division  is  into  acute  and  chronic  forms. 

An  analysis  of  the  various  forms  of  vaginitis  discloses  the  following 
varieties : 

1.  Gonorrheal. 

2.  Diphtheritic. 

3.  Exfoliative. 

4.  Emphysematous. 

5.  The  vaginitis  of  pregnancy. 

6.  Post-operative. 

7.  Senile. 

I  have  adopted  a  convenient  practical  classification  rather  than  one  which 
is  strictly  scientific. 

Gonorrheal  vaginitis,  perhaps  the  commonest  form,  is  frequently  found  in  the 
young,  especially  in  children,  whose  epithelial  tissues  are  more  readily  invaded 
hy  the  gonococcus.  In  the  earlier  stages,  it  is  associated  with  a  vulvitis 
hy  which  it  is  often  obscured  (gonorrheal  vulvo-vaginitis) .  The  disease  may 
remain  for  a  long  time  localized  in  the  vagina,  or  it  may  spread  rapidly  up 
through  the  uterus  and  out  into  the  uterine  tubes,  or  onto  the  peritoneum ;  often- 
times the  urethra  is  afi^ected  coincidently,  and  occasionally  the  bladder.  Even  in 
little  children  a  gonorrheal  peritonitis  is  not  uncommon.  Gonorrheal  vaginitis 
is  characterized  at  first  by  more  or  less  profuse,  yellowish  discharge,  associated 
with  heat  and  a  sense  of  fullness  and  bearing  down,  later  the  discharge  abates 
and  continues  without  any  local  discomfort :  a  febrile  reaction  is  sometimes 
seen  at  the  outset.  Gonorrheal  vaginitis  is  the  only  infectious  form, 
but  it  is  so  common  and  the  danger  of  infection  is  so  great,  that  every  case  of 
vaginitis  should  be  examined  microscopically,  to  determine  whether  or  not  the 
gonococcus  is  the  active  organism.  The  material  for  the  microscopic  exam- 
ination may  be  taken  at  the  vulvar  outlet,  or  a  speculum  may  be  introduced, 
and  a  little  of  the  purulent  material  gathered  on  the  end  of  a  platinimi  loop, 
and  sent  to  a  competent  pathologist,  as  already  directed. 

After  the  disease  has  persisted  for  some  time,  there  is  not  infrequently  a 
tendency  to  the  formation  of  little  iiapilhw  which  look  like  red  warty  gTOwths 
in  the  vagina  and  often  bleed  easily  on  being  handled.  This  condition  has  been 
investigated  particularly  by  C.  Ruge. 


FOKMS    OF    VAGINITIS.  281 

True  diphtheritic  vaginitis  has  been  frequently  observed  in  childhood,  asso- 
ciated with  various  grave  infectious  diseases,  and  is  characterized  by  the  ap- 
pearance of  diphtheritic  membrane  on  the  vulva  extending  into  the  vagina. 
In  diphtheria,  the  organism  at  work  is  the  bacillus  of  Loeffler ;  in  scarlatina, 
it  is  the  streptococcus.  A  diphtheritic  vaginitis  has  also  been  observed 
at  childbirth,  affecting  the  lacerated,  bruised  vaginal  tissues,  characterized  by 
swelling  and  redness,  and  an  excoriating  sanious  discharge,  accompanied  by  a 
deposit  of  diphtheritic  membrane  over  all  parts  of  the  vagina.  The  best  treat- 
ment for  this  serious  condition  is  first,  in  true  diphtheria,  to  use  antitoxin, 
and  second,  in  all  cases  to  make  free  use  of  local  washes.  It  is  well  to 
apply  the  tincture  of  chloride  of  iron  and  glycerin,  which  is  useful 
when  applied  to  the  throat,  by  saturating  a  pledget  of  cotton  with  it,  placing 
this  in  the  vagina,  and  leaving  it  in  situ  for  an  hour  or  more.  The  application 
should  then  be  removed  and  followed  by  a  warm  cleansing  boric  acid 
douche.  Where  the  hymen  is  unruptured,  warm  weak  bichloride  of  mercury 
douches  (1—10,000)  should  be  given  through  a  vesical  catheter  introduced  well 
up  into  the  vagina. 

An  exfoliative  vaginitis  is  one  characterized  by  casting  off  the  superficial 
epithelium  of  the  vagina  either  as  a  whole  or  in  parts.  Such  a  vaginitis  may 
be  provoked  by  a  strong  and  stringent  douche,  or  by  the  use  of  some  of  the 
patent  medicine  sujDpositories,  so  widely  advertised,  or  by  using  jequirity. 
One  of  these  suppositories,  analyzed  for  Dr.  Gellhorn,  contained,  besides  cocoa 
butter,  twenty-five  per  cent  of  dried  alum.  A  similar  exfoliation  occurs 
after  the  application  of  a  strong  solution  of  nitrate  of  silver  to  the  vagina. 
The  exfoliated  membrane  will  sometimes  lie  macerating  in  the  vagina  until  it 
is  removed.  On  placing  it  in  a  glass  vessel  full  of  warm  water,  the  membrane 
floats  out  and  its  true  nature  is  at  once  disclosed.  This  must  not  be  mistaken 
for  the  thin  rubber  covers  (condoms)  sometimes  accidentally  left  in  the  vagina 
and  discovered  by  the  physician.  After  the  exfoliation,  the  vaginal  mucosa  is 
a  little  redder  and  more  tender  for  a  few  days,  but  quickly  resumes  its  nor- 
mal appearance.  The  act  of  producing  an  exfoliation  by  a  drug  often  gives 
a  sense  of  relief  to  patients  who  are  suffering  from  pelvic  neuroses  or  mild 
disturbances,  and  this  fact  forms  the  basis  of  the  popularity  of  some  of 
the  reprehensible  nostrums  so  widely  advertised.  This  form  of  vaginitis 
has  been  particularly  studied  by  Gellhorn  (Amer.  Jour.  Ohst.,  1901,  vol.  44, 
p.  342). 

The  emphysematous  form  of  vaginitis,  first  described  by  Winckel,  is  rare, 
and  need  only  be  noted  in  passing.  The  vagina  is  covered  with  little  blebs 
which  contain  gas,  probably  due  to  the  invasion  of  some  rare  gas-forming 
bacillus. 

Vaginitis  of  Pregnancy. — ]S[ot  infrequently  a  peculiar  form  of  vaginitis  is 
seen  in  pregnancy,  characterized  by  heat,  redness,  and  swelling  of  the  parts, 
associated  with  a  curdy  discharge,  and  an  intense  itching.  The  latter  symptom, 
which  is  most  aggravating  and  distressing,  is  the  chief  reason  for  the  visit  to 


282  VULVITIS.       VAGINITIS.        CERVICITIS.       ENDOMETRITIS. 

the  physician.  It  is  sometimes  so  intolerable  as  to  make  the  life  of  the  patient 
almost  unbearable. 

Post-operative  Vaginitis. — Vaginitis  is  not  an  infrequent  sequel  to  radical 
operations  in  which  the  nterus  with  its  tubes  and  ovaries  is  amputated  above 
the  vaginal  vault  and  removed.  The  extirpation  of  these  organs  undoubtedly 
exercises  a  profound  effect  upon  the  pelvic  circulation;  the  nutrition  of  the 
parts  is  changed,  the  vagina  loses  its  rugosities,  its  walls  become  thinner  and 
smoother,  and  assume  a  senile  character.  With  these  changes  there  often  de- 
velops a  decided  vaginitis,  accompanied  by  a  milky  discharge  and  sometimes 
marked  by  patches  of  superficial  red  blotches  scattered  about  the  vault  of  the 
vagina.  The  whole  picture  is  not  unlike  that  of  senile  vaginitis,  although  there 
is  no  tendency  to  exfoliation  or  agglutination  of  the  walls  of  the  vagina  at  the 
vault. 

In  senile  vaginitis,  the  secretion  is  milky,  and  the  smooth  vaginal  walls  show 
irregular  jDatches  of  hyperemia,  while  the  epithelium  at  the  vault  of  the  vagina 
often  disappears,  and  the  adjacent  vaginal  walls  become  agglutinated,  in  time 
obliterating  the  vaginal  vault  and  forming  septa,  so  that  the  vagina  loses  its 
capaciousness  and  becomes  more  or  less  conical.  In  all  forms  of  vaginitis  the 
secretion  is  milky  or  creamy  or  curdlike,  but  never  mucoid  or  stringy. 

The  physician  must  never  forget  that  it  is  perfectly  within  the  range  of 
possibility  that  a  vaginitis  should  occur  which  is  due  to  his  own  hands 
or  instruments,  indeed  it  often  does  occur;  or  that,  in  a  patient  who 
already  has  a  vaginitis,  the  physician  may  himself  be  responsible  for  intro- 
ducing a  more  virulent  form  of  the  disease.  The  surest  way  to  do  this  is  by 
inoculation  with  an  unclean  pessary.  The  instrument,  taken  out  of  a 
patient  suffering  from  a  vaginal  infection,  is  perhaps  rinsed  in  a  little  warm 
water  and  laid  away  in  a  drawer,  and  then  introduced  into  the  next  patient, 
without  any  precautions  to  secure  sterilization.  The  patient  comes  back  in  a 
few  days  with  a  sense  of  heat,  swelling,  and  weight  in  the  parts,  due  to  the 
incipient  vaginitis,  which  thus  begins  to  run  its  protracted  course.  In  the  worst 
cases,  the  disease  may  even  go  farther  and  invade  the  uterine  mucosa  and  the 
uterine  tubes,  sealing  the  avenues  of  maternity.  The  same  infection  may  be 
brought  about  by  the  unclean  nails  and  hands  of  the  physician,  who  neglects 
to  wash  before  and  after  examining  each  case.  In  investigating  any  case  of 
florid  vaginal  infection,  thin  rubber  gloves  ought  always  to  be  worn  to 
protect  the  examiner's  hand  and  also  the  next  person  examined. 

Treatment. — The  best  position  in  which  to  examine  a  patient  is  in  the 
knee-breast  posture,  and  the  best  instrument  is  a  tubular  speculum  with  a  stout 
handle  (see  Eig.  T6).  This  enables  the  observer  to  see  all  parts  of  the  vagina, 
to  note  the  conditions  of  the  rug£e  and  of  the  parts  between,  and  also  to  see 
whether  there  is  an}^  pus  pouring  out  of  the  cervix.  In  the  more  acute  stages 
of  the  disease,  the  prominent  portions  of  the  vaginal  mucosa  along  the  ridges 
appear  swollen  and  much  reddened,  while  the  parts  between  the  prominent 
eminences  are  bathed  in  pus.     A  little  pressure  with  the  end  of  the  speculum 


TEEATMEISTT    OF    VAGIlSriTIS. 


283 


drives  the  blood  out  of  the  part,  which,  on  withdrawal  of  the  speculum,  appears 
for  the  moment  preternaturally  pale ;  the  blood,  however,  at  once  rushes  back 
into  the  dilated  capillaries.  In  the  more  chronic  forms  of  vaginitis,  the  dis- 
tribution of  the  disease  is  more  irregular  and  patchy  and  the  secretion  is  less. 


Fig.  76. — Treatment  of  Vaginitis  in  Knee-breast  Posture.  The  posterior  vaginal  wall  is  lifted  up, 
exposing  the  entire  vagina  tlioroughly  dilated.  1  he  examiner  is  engaged  in  putting  a  medicated 
gauze  pack  into  the  vagina  through  a  Sims'  speculum. 


The  treatment  of  vaginitis,  other  than  the  special  forms  already  spoken  of, 
may  be  carried  out  by  the  patient  herself  using  a  douche,  or  by  the  physician 
who  gives  local  treatments  at  his  office  or  at  the  bedside. 

Douches  are  most  useful  here,  as  they  serve  both  to  carry  away  the  irri- 
tating material,  and  to  heal  and  regenerate  the  diseased  tissues.  The  simplest 
form  of  douche  is  hot  water.  To  this  it  is  well  to  add  a  dessertspoonful  of 
common  salt  to  the  quart.  The  patient  should  take  a  hot  douche,  lasting  from 
five  to  ten  or  fifteen  minutes,  once  or  twice  a  day,  according  to  the  gravity  of 
the  affection.     The  temperature  of  the  water  at  first  should  be  105°  to  110°  Y., 


284 


VULVITIS.        VAGINITIS.        CEEVICITIS.       ENDOMETRITIS. 


and  this  should  then  be  increased  rapidly  up  to  120°  if  the  patient  can  stand 
it  without  much  discomfort.  While  taking  the  douche,  the  patient  should  rest 
in  an  easy  reclining  position,  with  her  hips  on  a  bedpan,  so  arranged  that  the 
overflow  is  conducted  to  a  waste-pipe.  The  douche  is  best  given  by  a  nurse  or 
an  assistant.  A  similar  douche  may  be  given  in  which  alum  is  used  instead 
of  salt,  in  the  same  quantity.  A  weak  solution  of  permanganate  of 
potash,  one  to  three  per  cent,  may  also  be  used  in  the  same  manner.  One 
of  the  most  refreshing  and  satisfactory  forms  of  vaginal  douches  is  the  com- 
pound menthol  powder,  which  I  have  now  used  for  some  fifteen  years. 
The  formula  for  it  is  as  follows: 

1^   01.  menth.  pip Sjss. 

Acidi  carbol.    .  .  , 5iij 

Alum,  pulv oj 

Acidi  borac oiv 

M.     S.   One  teaspoonful  to  one  quart  of  water. 

Treatment    at    the    Office    of    the    Physician. — Aside    from    the 
acute  cases,  all  forms  of  vaginitis  need  local  treatment,  such  as  can  only  be 

given  directly  by  the  hands 
of  the  physician,  and,  as  a 
rule,  best  at  his  office. 

Three  postures  are  use- 
ful, the  knee-breast,  the 
lateral,  and  the  dorsal. 
The  first  gives  the  best  ex- 
posure of  the  parts,  but 
when  the  patient  cannot  take 
the  knee-breast  position,  the 
physician  may  treat  her  in 
the  dorsal  or  in  the  Sims' 
posture. 

The  best  application  is 
one  of  nitrate  of  silver 
in  a  strong  solution.  Given 
a  bad  case  of  chronic  vagini- 
tis, the  disease  can  often  be 
literally  expunged  at  a  sin- 
gle treatment  by  an  applica- 
tion of  nitrate  of  silver  to 
all  parts  of  the  vagina.  It 
is  my  custom  to  do  this  in 
the  following  manner :  I 
take  a  swab  of  cotton,  thoroughly  saturated  with  a  solution  of  nitrate  of  silver, 
sometimes  twenty  per  cent,  or  in  milder  cases  as  weak  as  five  per  cent,  and 


Fig 


76A. — Cylindrical  Speculum  and  Alligator-Forceps 
Applicator,  Used  in  Treating  Vaginitis. 


Fig.  76B. — Cylindrical  Speculum  for  Vaginal  Treatments. 


TREATMENT    OF    VAGINITIS. 


285 


apply  this  carefully  to  every  part  of  the  vagina  until  the  whole  interior  from 
the  vaginal  vault  down  to  the  hymen,  including  the  cervix,  is  blanched  white ; 
no  part  should  escape.  This  is  readily  done  in  a  thorough  manner  by  turning 
the  speculum  first  in  one  direction  and  then  in  another  until  all  parts  are 
exposed  and  touched.  The  speculum  is  then  withdrawn,  taking  care  that  none 
of  the  solution  remains  inside  to  run  out  and  burn  the  surface  of  the  body. 
Sometimes  there  is  severe  aching  in  the  pelvis  after  a  treatment  of  this  kind; 
for  this  reason  the  patient  should  always  rest  for  several  hours;  indeed,  it  is 
a  wise  plan  to  keep  her  in  bed  for  several  days.  In  the  course  of  a  few  days, 
the  superficial  epithelium  sloughs  off  in  the  form  of  a  cast,  more  or  less  per- 
fect, and  is  discharged  with  a  bland,  purulent  secretion.  At  this  stage,  hot 
douches  should  be  used  of  permanganate  of  potash  or  of  Labar- 
raque's  solution  (Liquor  sodse  chlorinate,  see  p.  324),  one  or  two  table- 
spoonfuls  to  the  pint  of  water.  A  radical  treatment  of  this  kind  ought  not  to 
be  repeated  under  ten  to  twelve  days,  and  it  is  sometimes  better  to  wait  three 
or  four  weeks.  I  have  in  this  way  cured  post-operative  vaginitis  which 
has  resisted  all  other  kinds  of  treatment. 

The  treatment  of  vaginitis  by  packs,  as  a  rule,  is  rather  palliative 
than  curative.  It  consists  of  taking  pledgets  of  absorbent  cotton  about  the  size 
of  the  palm  of  the 
hand,  and  attached  to 
a  thread  for  the  pur- 
pose of  withdrawal. 
The  pledget  is  opened 
up  flat  and  made  sau- 
cershape,  a  teaspoon- 
ful  of  boroglycer- 
id  and  a  teaspoonful 
of  boric  acid  are 
laid  in  the  hollow, 
the  cotton  is  drawn 

over  the  fluid,  and  the  bolus  is  then  introduced  in  the  vault  of  the  vagina  with 
a  dressing  forceps.  If  the  vagina  is  capacious,  one  or  more  dry  packs  may  be 
applied  below  this.  The  patient  should  remove  this  pack  within  twenty-four 
hours  by  pulling  on  the  string  which  is  left  hanging  outside,  after  which  she 
may  take  the  douche  recommended  on  page  284. 

Another  good  treatment  of  vaginitis,  through  the  cylindrical  speculum,  with 
the  patient  in  Sims'  posture,  is  the  use  of  the  puff  box,  commonly  employed 
for  distributing  insect  powder,  fllled  with  fine  boracic  acid  powder,  which 
is  blown  in  through  the  speculum,  and  thus  applied  to  all  parts  of  the  vaginal 
walls.  A  little  camphor  may  be  mixed  with  the  powder,  say  two  or  three 
grains  to  the  ounce. 

In  treating  vaginitis,  it  is  well  to  proceed  somewhat  in  the  following 
order i 


Fig.  76C. — Instrument  and  Materials  for  Treating  Vaginitis. 


286 


VULVITIS.       VAGINITIS.        CERVICITIS.        EXDOMETEITIS. 


(1)  Prescribe  douches,  such  as  the  boracic  acid,  or  soda  and  alum 
douche,  to  be  used  daily.     Try  this  for  three  or  four  weeks. 

(2)  Try  the  vaginal  packs,  applying  them  twice  a  week  for  three  or 
four  weeks,  or  alternate  the  daily  douches  with  a  pack  about  once  a  week. 

(3)  Make  the  application  of  nitrate  of  silver  to  the  walls  of  the 
vagina,  using  the  strong,  twenty  per  cent  solution,  as  a  rule,  only  in  bad 
inveterate  cases. 

In  all  eases  of  vaginitis  a  lingering  cervicitis,  should  it  happen  to 
be  present,  must  be  cleared  up.     I  have  found  it  of  value  in  a  case  of  vaginitis 

following  confinement  in  a  stout 
woman,  with,  breaking  down  of  the 
outlet  and  eversion  of  the  vaginal 
walls,  to  thoroughly  restore  the  out- 
let, saving  the  tissues  from  attrition 
and  preventing  the  hyperemia  aris- 
ing from  congestion  and  imperfect 
circulation. 

Yeast  Treatment. — Within 
the  last  few  years  a  method  of  treat- 
ing vaginitis  by  means  of  yeast  has 
been  introduced,  which  has  had  ex- 
cellent results  in  some  cases.  I  cite 
as  a  competent  authority  H.  Schil- 
ler (Amer.  Jour.  Ohst.,  1905,  vol. 
51,  p.  635).  The  treatment  was 
introduced  by  Landau  in  gonor- 
rheal vaginitis  with  the  idea  that  the  rapid  gTOwth  of  the  yeast  would 
drive  out  the  gonococcus  by  depriving  it  of  food  and  water.  Schiller 
treated  ten  patients  with  good  results,  and  there  were  no  bad  effects  in  any 
case,  though  some  of  the  women  complained  of  itching  for  a  couple  of  days. 
The  yeast  used  is  best  secured  fresh  from  a  brewery.  After  cleansing  the 
vagina  with  sterile  water,  two  teaspoonfuls  of  yeast  and  one  teaspoonful  of 
grape  sugar  solution  are  introduced  into  the  vagina  through  a  speculum,  in 
such  a  manner  that  the  portio  vaginalis  and  the  walls  of  the  vagina  are  bathed 
in  it.  If  this  can  be  done  at  the  patient's  home,  it  is  desirable.  After  the 
lapse  of  a  few  minutes,  a  tampon  saturated  with  the  grape  sugar  solution  is 
introduced,  and  after  from  eight  to  ten  hours  a  vaginal  douche  should  be  used. 
The  treatment  is  repeated  every  forty-eight  hours.  The  cases  most  suitable 
for  the  yeast  treatment  are  es^Decially  the  gonorrheal  inflammations, 
both  acute  and  chronic ;  cases  of  purulent  vaginitis  and  endocervicitis 
which  are  not  gonorrheal  in  character  are  also  benefited. 


Fig.   76D. —  Appllotce    for    Distending   Vagina 
WITH  Water  or  Air. 


SYMPTOMS    OF    CERVICITIS.  287 


CERVICITIS   AND    END O CERVICITIS. 

Symptoms. — When  an  infection,  gonorrheal  or  otherwise,  lodges  in  the  cer- 
vical glands,  the  cervix  becomes  considerably  enlarged  and  sometimes  enor- 
mously hypertrophied.  The  mucosa  is  everted,  exposing  the  reddened  lining 
membrane  of  the  cervix,  and  the  glands  become  hypertrophied  and  excessively 
active,  pouring  out  a  whitish,  albuminous  or  muco-purulent,  tenacious  secre- 
tion. This  is  seen  choking  the  cervical  canal  and  overflowing  into  the  vaginal 
vault.  The  picture  of  such  a  weeping  cervix  is  quite  characteristic.  It  should 
be  remembered  that  this  affection  is  designated  by  the  patient  as  the  "  whites," 
and  is,  of  course,  not  distinguished  by  her  from  a  vaginal  leucorrhea.  The 
secretion  thus  formed  is  apt  to  accumulate  in  the  vaginal  vault,  and  sometimes 
a  large  quantity  of  muco-pus  is  thus  retained  back  of  and  under  the  cervix, 
which,  when  the  patient  rises  in  the  morning,  is  discharged  en  masse.  Such  a 
discharge  is  a  continual  distress ;  it  produces  a  sense  of  uncleanliness,  and  the 
patients  thus  affected  feel  obliged  to  wear  constantly  some  protective  dressing, 
such  as  a  gauze  pad  and  a  bandage.  They  are  as  much  inconvenienced  as  by 
a  continuous  menstruation.  It  is  important  to  note  particularly  that  the  cer- 
vical discharge  is  stringy  and  more  or  less  like  the  white  of  an  egg,  in  this 
way  differing  from  the  curdy,  or  milky,  or  creamy  vaginal  discharge.  The 
affected  glands  are  not  infrequently  closed,  when  the  discharge  accumulates 
within,  and  converts  the  cervix  into  a  series  of  cysts  (ISTabothian  follicles), 
some  of  which  are  seen  on  the  vaginal  surface,  while  others  niay  be  found  far 
up  in  the  cervical  canal,  extending  out  into  the  walls  of  the  cervix  proper.  In 
rare  instances  the  entire  cervix,  from  the  internal  os  down,  is  converted  into 
a  mass  of  these  cysts,  until  the  cervix  is  literally  honeycombed,  I  have  seen  a 
case  in  which  the  lower  segment  of  the  uterus  appeared  to  be  converted  into 
a  large  tumorous  mass,  from  nothing  else  than  an  enormous  development  of 
these  choked  cervical  glands.  The  disease  causes  no  pain,  but  it  is  objection- 
able because  the  continual  discharge  is  weakening  to  the  patient,  and  because 
the  presence  of  an  infection  at  the  ostium  of  the  womb  is  a  continual  menace 
to  the  tissues  above,  making  the  patient  more  liable  to  a  uterine  and  a  tubal 
infection.  Almost  all  of  these  cases  of  muco-purulent  cervices  are  due  to  a 
gonorrheal  infection.  The  disease  may,  however,  follow  an  infection  by  other 
pyogenic  organisms  in  childbirth.  The  presence  of  a  cervical  infection  of  this 
kind  does  not  necessarily  indicate  any  similar  disease  of  the  body  of  the  uterus 
above  it. 

It  is  a  common  practice  among  women  to  use  a  cleansing  vaginal  douche 
just  prior  to  consulting  the  physician  with  reference  to  pelvic  complaints.  The 
examiner  is  thereby  obviously  deprived  of  a  valuable  and  important  diagnostic 
aid,  namely,  the  character,  amount  and  source  of  the  leucorrheal  discharges. 
Patients  should  be  carefully  instructed,  therefore,  not  to  use  a  douche  on  the 


288  VULVITIS.       VAGINITIS.        CERVICITIS.        ENDOMETRITIS. 

day  of  the  cxainination ;  and  it  should  be  a  routine  practice  to  make  a  careful 
microscopic,  as  well  as  macroscopic,  study  of  the  discharges  present. 

Treatment. — Cervicitis  is  one  of  the  most  obstinate  of  all  gynecological  affec- 
tions. It  cannot  in  any  way  be  reached  by  vaginal  douches,  which  serve  merely 
to  remove  the  debris  that  has  accumulated  in  the  vaginal  vault.  Patients  sub- 
jected to  mild  treatments  by  applications  will  be  obliged  to  frequent  the  office 
of  the  doctor  year  after  year  without  gaining  any  substantial  relief. 

The  first  step  in  the  treatment  is  to  puncture  any  cysts  that  may  be 
seen  projecting  from  the  cervix.  In  mild  cases  the  cervix  may  be  exposed  with 
the  patient  in  the  dorsal  position,  and  after  placing  a  suitable  pack  behind  it,  an 
application  may  be  made  of  a  strong  solution  of  nitrate  of  silver,  twenty 
or  thirty  per  cent  strength.  This  may  be  rejDeated  about  once  in  ten  days,  the 
patient  in  the  meantime  using  cleansing  douches.  The  more  aggravated  cases  of 
this  class  are  those  in  which  our  predecessors  used  to  employ  the  solid  stick 
of  nitrate  of  silver,  pushing  it  up  into  the  cervical  canal  and  leaving  it 
there.  The  result  of  this  was  an  extensive  destruction  of  the  contiguous  tis- 
sues, destroying  and  curing  the  endocervicitis,  but  often  resulting  in  the  for- 
mation of  cicatricial  tissue,  leaving  behind  an  almost  bony  cervix,  and  in  the 
event  of  pregTiancy,  giving  rise  to  serious  complications,  on  account  of  cervical 
rigidity.  This  practice  is  not  to  be  recommended.  If  the  patient  has  borne 
children,  and  the  cervix  is  lacerated  and  everted  as  well  as  infected,  the  best 
plan  of  treatment  is  to  excise  the  diseased  mucosa  (resection  of  the  cervix). 
This  operation  is  simple,  safe,  and  effective,  if  carefully  done.  Incisions  are 
made  in  each  lateral  angle  between  the  anterior  and  posterior  lips,  a  wedge  is 
then  excised  from  each  lip,  care  being  taken  to  remove  the  mucosa,  but  as 
little  of  the  vaginal  portion  of  the  cervix  as  possible.  The  lips  excised  in 
this  way  may  then  be  brought  together  by  catgut  sutures.  An  iodoform  gauze 
pack  should  be  placed  in  the  vaginal  vault,  and  the  jDatient  kept  in  bed  for 
five  days,  after  which  she  may  get  up  into  a  chair  and  the  pack  may  be 
removed.  A  few  days  after,  douches  of  hot  boric  acid  solution^  half 
saturated  strength,  should  be  used  once  daily. 

Where  there  is  no  laceration,  or  it  is  thought  best  not  to  operate,  a  most 
effective  plan  of  treating  these  bad  cervical  infections  is  by  the  use  of  the 
actual  cautery,  as  recommended  by  Dr.  Guy  L.  Ilunner.  The  cervix  is 
exposed  in  the  dorsal  position,  with  a  ISTelson  trivalve  speculum,  the  vaginal 
vault  is  protected  by  a  gauze  pack,  leaving  the  diseased  cervix  exposed  in  the 
middle;  then  grasping  the  anterior  lip  to  fix  the  cervix,  the  cautery,  heated 
to  a  bright  red,  is  used  to  burn  out  and  char  the  diseased  tissues  on  all  sides, 
and  well  up  into  the  cervical  canal.  There  are  two  ways  of  doing  this :  one 
is  to  char  out  the  cervix,  aiming  to  burn  the  tissues  to  the  depth  of  three  to 
four  millimetres  in  every  direction,  leaving  a  black,  unsightly  cervical  mucosa. 
The  other  is,  to  introduce  the  well-heated  cautery  well  into  the  cervical  canal 
and  make  two  or  three  deep  linear  cauterizations,  not  attempting  to  burn  all 
the  tissues.     Dr.  Hunner  has  found  the  latter  plan  both  simple  and  effective. 


TREATMENT    OF    CERVICITIS. 


289 


The  patient  should  come  back  for  a  repetitoii  of  these 
treatments  from  once  in  ten  days  to  once  in  two 
weeks.  A  marked  improvement  will  be  noted  each 
time.  I  have  myself  repeatedly  employed  the  plan 
of  extensive  cauterization  with  happy  results.  It 
is  well  to  wait  six  or  eight  weeks,  or  even  longer, 
after  cauterizing  deeply. 

The  simple  cauterizations  do  not  call  for  an  anes- 
thetic. If  the  patient  is  nervous,  a  little  weak  so- 
lution of  coca  in,  two  grains  to  the  ounce,  may  be 
injected  into  the  cervix  to  benumb  it.  For  the  more 
extensive  cauterizations,  it  is  well  to  give  a  general 
anesthetic,  but,  as  the  operation  is  a  short  one,  nitrous 
oxide  gas  is  satisfactory  for  this  purpose.  Follow- 
ing the  more  extensive  operations,  the  patient  ought 
to  rest  for  two  or  three  days  in  bed.  The  lighter 
operations  may  be  done  in  the  office,  the  patient 
going  home  shortly  afterwards.  It  is  w^ell  to  fore- 
warn a  woman  treated  in  this  way  that  in  about  a 
week  or  ten  days  there  will  be  a  slightly  bloody  and 
increased  purulent  discharge ;  this  will  prevent  any 
discouragement.  In  all  these  difficult  cases,  the  dis- 
ease can  be  cured  by  this  method  without  completely 
destroying  the  cervical  glands,  and  without  leaving 
behind  any  troublesome  cicatrices.  A  word  of  cau- 
tion is  necessary,  however,  and  that  is,  to  note  that 
Dr.  Hunner  has  seen  one  case  of  infection  travelling 
up  into  the  tubes,  which  may  have  been  due  to  the 
suppuration  in  the  cervix,  brought  on  by  the  use 
of  the  cautery.  Prompt  and  marked  improvement, 
even  in  the  worst  cases,  always  follows  this  treat- 
ment. If  the  thorough  burning  out  is  used,  one  or 
two  treatments  will  often  suffice.  I  expect  after  the 
first  treatment  to  note  from  seventy-five  to  ninety 
per  cent  improvement  in  the  condition.  I  have  in 
this  way  cured  a  patient  who  had  been  on  my  hands 
for  many  years  without  material  change  and  she  has 
remained  several  years  without  a  relapse. 

Craig's  method  of  treatment  of  endocervicitis 
is  simpler  and  safer  than  the  one  just  described 
(Trans.  South  Surg.  Assoc,  1905,  vol.  18,  p.  342). 
It  consists  in  the  suitable  exposure  of  the  diseased 
cervix,  thorough  cleansing  of  the  parts,  and  a  slight 
dilatation  of  the  canal,  followed  by  the  thorough 
20 


it 


Fig.  77. —  Craig's  Shaep  Cv- 
eette  for  scraping  out  the 
Diseased  Cervical  Glands 
IN  Gonorrheal  and  Other 
Forms  of  Endocervicitis. 


290  VULVITIS.       VAGINITIS.        CERVICITIS.       ENDOMETRITIS. 

use  of  a  sharp  curette  (see  Fig.  77).  This  serves  to  break  down  the  dis- 
eased giauds,  lay  them  widely  open,  clean  them  out,  and  drain  them.  It 
is  surprising  to  note  how  much  tissue  is  removable  by  the  curette  from  the 
rigid  cervix.  This  treatment  may  have  to  be  repeated  several  times,  at  inter- 
vals of  a  couple  of  weeks.  It  is  in  the  end  most  effective  and  satisfactory. 
After  such  a  cervical  curettage  it  is  well  to  put  a  boroglycerid  pack  against 
the  vault  of  the,  vagina,  which  is  left  in  situ  for  twelve  hours,  and  then  with- 
drawn and  followed  by  a  hot,  half-saturated  boracic  acid  douche. 

In  extremely  obstinate  cases,  resisting  all  other  plans  of  treatment,  a  cir- 
cular amputation  of  the  cervix  will  give  relief.  This  is  decidedly  a 
major  gynecological  operation,  however,  and  should  only  be  undertaken  by  those 
prepared  to  do  a  hysterectomy,  should  it  be  rendered  necessary  by  profuse 
bleeding  occasioned  by  the  operation. 


RAKITY    OF    TRUE    ENDOMETKITIS.  291 


ENDOMETRITIS. 


A  true  endometritis  is  an  inflammatory  affection  of  the  endometrium,  due 
to  the  gonococcus,  to  other  pyogenic  infecting  organisms,  or  to  the 
tubercle  bacillus.  A  variety  of  changes  in  the  endometrium,  however, 
characterized  by  a  hyperplasia  and  dilatation  of  the  glands  are 
included  under  the  head  of  endometritis  which  do  not  properly  and  in  a  strict 
sense  belong  there.  True  endometritis  is  seen  in  its  best-defined  form 
in  the  acute  condition  in  the  puerperal  woman,  or  after  a  septic  abortion  due 
to  a  septic  or  sapremic  infection.  The  acute  form  is  rarely  seen  outside  of 
the  puerperal  state;  a  gonorrheal  endometritis,  for  example,  which  is 
most  evident  in  the  cervix,  travels  upwards,  and  often  creates  no  particular 
recognizable  symptoms  as  it  traverses  the  uterus  until  the  uterine  tubes  are 
involved.  In  examining  many  specimens  of  endometria,  it  is  rare  to  find  signs 
of  true  inflammation,  or  evidences  of  any  organisms  deep  down  in  the  glands 
or  in  the  submucous  tissue. 

Out  of  eighteen  hundred  cases  occurring  in  my  own  service  and  analyzed 
by  Dr.  T.  S.  Cullen,  endometritis  showing  definite  inflammatory  changes, 
exclusive  of  tuberculosis,  was  found  only  forty-nine  times.  The  mucosa 
of  the  uterus  was  studied  in  every  case  where  that  organ  had  been  removed, 
or  where  scrapings  were,  taken,  including  many  cases  of  myomata  and  of  pus 
tubes.  We  found  that  even  where  there  was  a  pyosalpinx  on  one  or  both  sides, 
the  uterine  mucosa  was  often  perfectly  normal.  This  exemption 
seems  undoubtedly  due  to  the  fact  that  the  uterus  is  so  easily  drained  that  the 
infectious  material  is  not  retained  long  enough  to  provoke  and  maintain  an 
inflammation. 

Tubercular  endometritis  is  always  of  a  chronic  form,  with  the 
single  exception  of  the  rare  miliary  condition,  when  the  general  state 
of  the  patient  is  so  bad  that  there  is  nothing  to  draw  attention  to  the  local 
trouble.  In  the  chronic,  diffuse  tuberculosis,  yellowish  nodules  are 
seen  under  the  surface  of  the  mucosa,  one  to  two  millimetres  in  diameter. 
If  the  disease  is  advanced  and  the  mucosa  is  broken  down,  shallow,  ulcerated 
areas  appear.  Sometimes  in  the  more  advanced  cases,  a  caseous  material  is 
poured  out.  Tubercles  show  giant  cells  from  the  fusion  of  protoplasm  of  a 
number  of  cells  which  still  retain  their  distinct  nuclei. 

Tubercular  endometritis,  as  a  rule,  causes  no  marked  uterine  symp- 
toms except  in  an  advanced  form,  and  it  is  oftenest  recognized  because  of  its 
almost  invariable  association  with  a  tubal  tubercular  disease.  If  a  tubo-ovarian 
mass  is  present  and  curettings  of  the  uterine  mucosa  show  tuberculosis,  it  is 
safe  to  say  that  the  disease  of  the  tubes  is  tubercular. 

Gronorrheal  endometritis  is  oftenest  noted  after  an  abortion,  or  in 
the  puerperium,  when  the  hyperemic  state  of  the  tissues  favors  the  recrudes- 


292 


VULVITIS. 


VAGINITIS. 


CERVICITIS. 


ENDOMETRITIS. 


cence.  transmission,  and  lodgment  of  the  disease.  The  lijjjcrcniia  of  men- 
struation also  favors  the  advance  of  the  disease  to  the  uterine  mucosa. 

Such  diseases  as  glandular  and  polypoid  endometritis  are  not 
true  inflammatorj  affections  though  classified  under  this  head  by  general 
consent. 

It  is  safe  to  say  that  in  ninety-nine  out  of  one  hundred  cases  when  a 
physician  curettes  the  nterus  for  endometritis,  and  removes  more  or  less  endo- 
metrium, no  real  endometritis,  in  the  sense  of  a  chronic  inflammatory  affec- 
tion, is  present.  Tme  endometritis  is  a  disease  as  rare  as  cervi- 
citis and  endocervicitis  are  common.  The  term  endometritis  has 
served  as  a  sort  of  waste-basket  for  the  gynecologist  to  which  obscure  troubles, 
not  referable  to  any  other  well-defined  disease,  are  commonly  referred  as  a 
matter  of  convenience.  It  has  in  these  days  taken  the  place  of  metritis,  to 
which  Scanzoni  gave  so  much  attention  in  the  early  sixties.  A  metritis  is 
actually  one  of  the  rarest  of  rare  gynecological  affections,  and  one  which, 
outside  of  the  puerperal  state,  is  never  recogTiized  intra  vitam.  One  of  the 
reasons  why  there  exists  so  much  confusion  regarding  endometritis,  as  Doder- 
lein  and  Kronig  put  it,  is  that  "  in  an  organ  so  rich  in  glands  as  the  uterus, 


Fig.  78. — Polypoid  Endometritis.  (Natural  size.")  J.  H.  H.  Gjm.-Path.  No.  1466.  The  uterus 
and  appendages  were  removed  on  account  of  salpingitis  and  general  pehnc  peritonitis.  The  uterus 
is  enlarged;  its  walls  are  thickened  and  extremely  dense.  The  entire  uterine  ca^^ty  is  lined  by 
a  shaggy  inucosa,  consisting  of  small  stubby  polypi,  which  point  toward  the  internal  os.  These 
vary  considerably  in  size,  but  the  majority  of  them  are  of  the  same  size  and  have  rounded  ends. 
The  junction  between  these  outgrowths  and  the  muscle  is  not  sharply  defmed,  nor  is  there  any  evi- 
dence that  the  muscle  has  been  invaded.     (From  T.  S.  Culleh.) 


VAKIETIES    OF    SO-CALLED    ElSfDOllETKITIS.  293 

it  is  diflficult  to  describe  an  exact  type  of  structure  to  which  all  cases  ought 
to  conform.     It,  therefore,  beco]nes  possible  for      ^ 

the  clinician  to  discover  the  desired  pathologico-  "^L 

anatomical  substratum  in  any  given  case."  -.^ 

For  the  sake  of  avoiding  confusion  I  here  use  .;^ 

the  term   endometritis   as  it  is  commonly  em-  -rt^ 

ployed.    The  changes  in  the  uterine  mucosa  affect  .  .   SZ^ 

either  the  glands,  or  the  interstitial  tissue,  or  the  *  ^^^    ■ 

entire  structure  of  the  mucosa.     These  changes     ■    ^  '^^'l 

are  recognized  under  the  following  names:  "'•         \  -'-  'i^^i 

Glandular  endometritis  or  glandular  hyper-  '    ^    y  ^'^P 

trophy.  ^  ^  ^  ^-,        'vV^,  -^    -" 

Hvpertrophic  endometritis.  %  *'^ 

Hyperplastic  endometritis  or  polypoid  endo-      . '  --S 

metrium.  ^  *'  '^\ 

Interstitial  endometritis.  ^\  \  ,W 

Senile  endometritis  or  atrophy.  <   ^  »  y?j 

There  is  no  symptom  characterizing  any  mem- 
ber of  this  group  except  the  senile  form  and  the 
differential   diagnosis   is   purely   an   act   of   the         X 
laboratory. 

The  chief  symptom  calling  for  treatment  of        *  '••»  "   '--J  '-^ 

the    endometrium    is     excessive     menstrual     '  -x  /       •   ■.       '  ;"^^ 
flow.     Aside  from  this,  it  is  common  to  curette      5^.-.  :'| 

for  supposed  infection  and  for  menstrual  "^ 

pain. 

The  patients  suffering  from  endometritis  of 
the    non-infectious    form,    who    most    urgently       .  ^ 
demand    relief,    are   for    the    most    part    young        > 
women,   whose  sole   symptom   and  complaint  is      "^  ^  <»*  '  • , 

excessive   hemorrhage    at   the   menstrual    period  ; 

or  extension  of  the  flow  beyond  its  normal  dura- 
tion. These  patients  in  aggravated  cases  are 
waxy,  almost  hydremic,  short  of  breath  and  in-  ^  'J 

capable  of  any.  other  than  a  most  sedentary  exist-       >,  -v 

ence.     The  hemorrhage,  at  first  bright,  becomes     ^  X  ^      -.) 

watery  as  it  is  prolonged.     It  is  not  too  much  *>  .   "      \    ■ 

to   say   that   the   bleeding   is   sometimes    fright-      ^^^  \  '     .  ^, 

ful.      The  anatomical  basis  of  this  hemorrhage  ~  ,  ^  "1 

Fig.  79. — A  Polypoid  Endometritis,  showing  a  Section  of 

THE  Endometrium  with  some  of  the  Underlying  Mus-  ^ 

CULARIS  taken  FROM  A  PoiNT  NEAR  THE  MiDDLE  OP  THE    . 

Uterine  Cavity.      The  redundant  polypoid  condition  of  .._^-^- •-- .--■     -  ^^^^^^^^^^r^^ 

the  mucosa  hanging  downward  toward  the  cervix  is  evident. 

The  surface  of  the  polypi  is  covered  with  a  single  layer  of  epithelium  continuous  with  that  of  the  tm- 

derlying  glands,  while  the  stroma  is  abundant  and  dense,  owing  to  a  marked  small  round-celled  inl.l- 

tra,tion.    The  uterine  glands  are  diminished  in  number.    Froni  T.  S.  Cullen, ' '  Cancer  of  the  Uterus." 


:^-v 


294  -^TTLYITIS.       TAGIXITIS.        CEEVICITIS.       EXDOMETEITIS. 

resembles  a  condition  of  multiple  polypi  choking  the  nterine  cavity  (see 
Fiff.  78).  The  elands  are  ereatlv  dilated  and  the  blood  vessels  increased  in 
number  and  size,  but  there  is  no  evidence  of  invasion  of  the  muscle,  as  is  the 
case  in  adeno-carcinoma.  A  microscopic  examination  of  the  curettings  should 
be  made  in  all  cases,  in  order  not  to  mistake  a  cancer  or  a  sarcoma  for  the 
disease  in  question  (see  Tig.  79).  The  methods  of  treatment  are  by 
chemical  cautery  or  by  the  use  of  nitric  acid  or  nitrate  of  silver 
to  the  interior  of  the  uterus.  The  risk  of  setting  up  an  inflammation  in  the 
uterine  tubes  by  the  use  of  these  drugs  is  so  gTcat  that  they  ought  to  be  gen- 
erally abandoned.  The  actual  cautery  has  been  used  in  the  form  of  air 
(zestokausis),  and  steam  (atmokausis).  It  is  difficult  to  regulate  these  agents 
and  prevent  them  from  burning  too  deeply  into  the  "svalls  of  the  uterus,  thus 
producing  sloughs ;  for  this  reason  I  do  not  recommend  their  use. 

The  third  method  of  treatment,  curettage,  is  the  safest  of  all.  This 
should  be  preceded  by  a  dilatation  of  the  cervix,  and  followed  by  a  thorough, 
gentle  use  of  a  sharp  curette  by  the  method  described  in  detail  in  Chapters 
IV  and  YII,  pp.  123  and  189. 

SENILE    ENDOMETRITIS. 

A  senile  endometritis  differs  markedly  in  some  of  its  clinical  aspects  from 
the  ordinary  forms  foimd  earlier  in  life.  A  careful  description  of  this  affec- 
tion has  been  given  by  H.  L.  Dunning  (Jour.  Amer.  Med.  Assoc,  1904,  vol. 
43,  p.  767).  The  "vvomb  is  small  and  shovs  no  marked  changes  in  the  body. 
The  diseased  endometrium  pours  out  a  milky  purulent  discharge.  This  is 
often  associated  ^vith  erosion  of  the  cervix  and  erosion,  adhesions,  and  con- 
tractions at  the  vaginal  vault.  The  vagina  itself,  bathed  in  the  irritating 
secretions,  is  smooth,  reddened,  and  often  covered  with  reddish  patches.  The 
discharge  accumulating  in  it  is  often  offensive.  A  vulvitis  of  the  shrivelled 
external  genitals  may  be  present  and  marked  by  intense  itching.  The  puru- 
lent or  bloody  purulent  discharges  from  the  uterus  are  often  mistaken  for 
signs  of  carcinoma. 

It  is  in  these  cases  that  the  cervix,  having  lost  its  epithelium,  sometimes 
becomes  agglutinated,  converting  the  uterus  into  a  closed  cavity  which  becomes 
distended  with  the  accumulation  of  discharges  and  converted  into  a  pyometra, 
or  if  gas  also  forms,  into  a  pyo-physometra.  The  patient,  is  apt  to  suffer 
from  distress  and  burning  in  the  lower  abdomen  and  this  is  gTeatly  aggTavated 
if  the  cervix  becomes  closed.  Owing  to  absorption  of  the  poisonous  products 
there  may  be  anemia  and  cachexia.  The  ordinary  senile  endometritis  is  not 
associated  with  fever. 

The  inflammatory  changes  are  found  in  the  thin  senile  endometrium  in 
which  the  glands,  after  dipping  for  a  short  distance  below  the  surface,  turn 
to  extend  parallel  to  the  myometrium. 

The  treatment  is  by  dilatation  for  drainage  and  the  application  of  weak 
solutions  of  nitrate  of  silver  (five  to  ten  per  cent). 


CHAPTER    XII. 

PRURITUS.     VAGINISMUS.     MASTURBATION. 

(1)  Pruritus:    Definition,  p.  295.     Etiology,  p.  295.     Symptoms  and  diagnosis,  p.  297.     Treat- 

ment, p.  297. 

(2)  Vaginismus:    Definition,  p.  304.     Etiology,  p.  304.     Prognosis,  p.  306.     Treatment,  p.  306. 

(3)  Masturbation:   General  considerations,  p.  309.     Etiology,  general  and  local,  p.  310.     Preva- 

lence, p.  310.     Methods,  p.  311.     Clinical  findings,  p.  312.     Effects,  p.  314.     Diagnosis, 
p.  314.     Preventive  treatment,  p.  314.     Curative  treatment,  p.  315. 

PRURITUS. 

Definition. — Pruritus  is  a  general  term  wliicli  signifies  neither  more  nor  less 
than  an  itching.  Hebra  defines  pruritus  as  a  chronic  disease  of  the  skin,  which 
though  lasting  for  months  and  years  may  be  characterized  by  no  other  symptom 
than  itching.  The  skin  may  show  no  alteration  at  all,  or  else  only  such  as 
arises  from  the  constant  scratching  of  the  parts  excited  by  the  intense  irritation. 
The  term  pruritus  is  used  here  to  designate  simply  an  itching  of  the  vulva. 

Etiology. — The  changes  in  the  skin,  so  often  observed  in  pruritus,  are  sec- 
ondary to  the  disease,  and  arise  from  the  itching  and  consequent  scratching 
or  else  from  the  presence  of  irritating  discharges.  These  secondary  changes 
do  not  constitute  the  affection,  though  they  undoubtedly  aggravate  it,  and  for 
this  reason  the  physician  must  always  look  behind  the  superficial  affection 
for  some  one  of  the  variety  of  causes  in  which  it  may  have  originated  and  by 
which  it  is,  as  a  rule,  maintained.  In  many  cases  the  profound  skin  changes, 
when  once  induced,  are  sufficient  in  themselves  to  keep  up  the  pruritus  even 
after  the  original  cause  is  removed ;  in  fact,  these  cases  move  in  a  truly  vicious 
circle :  the  itching  provokes  scratching,  and  the  scratching,  in  its  turn,  causes 
changes  in  the  skin  which  excite  more  itching,  and  this  again  provokes  the  desire 
for  relief  by  renewed  scratching,  and  so  the  disease  grows  constantly  worse,  feed- 
ing itself  upon  the  very  means  which  the  victim  instinctively  seeks  for  relief. 

In  general  two  sets  of  causes  are  recognized  as  inducing  pruritus,  and 
perhaps  a  third.     These  are : 

(1)  Irritating  secretions,  acting  upon  the  parts  and  often  associated  with 
a  local  infection. 

(2)  Neuroses. 

(3)  Blood  alterations. 

Diabetes  may  be  cited  as  an  example  of  the  third  class.  Sanger  con- 
sidered that  the  pruritus  observed  in  diabetes  was  hematogenous  and  analogous 
to  the  pruritus  seen  in  jaundice.  Many  authorities  believe,  however,  that  the 
local  action  of  the  urine  is  sufficient  in  itself  to  explain  the  presence  of  irri- 

295 


296 


PETJEITUS.       VAGINISMUS.        MASTTJKBATION. 


tation  in  this  locality.  Yeit  points  out  that  men  with  diabetes  suffer  from 
pruritus  of  the  scrotum  and  believes  that  the  irritation  is  due  to  some  other 
constituent  in  the  urine  than  grape  sugar,  as  he  tried  putting  gTape  sugar 
compresses  on  the  vulva  of  some  patients  without  provoking  itching.  It  is  an 
interesting  question  how  far  pruritus  is  associated  with  constitutional  gout. 

As  to  the  neurotic  form  of  pruritus,  the  term  is  used  in  a  general 
sense,  as  it  is  in  nervous  dyspepsia,  being  often  employed  to  cover  an  igno- 
rance of  the  true  local  cause.  It  should  be  recognized  that  the  term  is  one  of 
convenience  only,  such  as  we  are  still  often  obliged  to  use,  so  long  as  we  are 
unable  to  discover  locally  acting  causes. 

The  most  satisfactory  group  of  cases  is  that  constantly  enlarging  one  in 
which  the  disease  can  be  attributed  to  some  irritating  or  infectious 
secretion,  continually  discharged  over  the  parts,  and  thus  keeping  up  a 
constant  irritation.  It  is  possible  that  eventually  some  hitherto  unrecogTiized 
organism,  peculiarly  adapted  to  gTOwing  in  the  moisture  and  secretions  of  the 
parts,  will  be  found  at  the  bottom  of  almost  all  cases,  and  we  shall  be  able  to 
refer  a  large  number  of  them  to  a  uniform  cause. 

"Webster  considers  that  pruritus  consists  essentially  in  a  slowly  progres- 
sive fibrosis  of  the  parts  (subacute  inflammation  of  the  papillary 
bodies),  especially  of  the  labia  minora  and  the  clitoris,  by  which  the  nerves 
and  their  endings  are  chiefly  involved.  Leopold  holds  that  pruritus  is  almost 
always  due  to  an   old   chronic  endometritis. 

The  following  causes  of  pruritus  must  be  kept  before  the  physician  when 
he  investigates  any  particular  case : 


(1) 

Pediculus  pubis. 

(2) 

Ascarides, 

(3) 

Thrush. 

(4) 

Diabetes. 

(5) 

j^ephritis. 

(6) 

Menstrual  discharge. 

C^) 

Gonorrhea. 

(8) 

Vaginitis. 

(9) 

Pessaries. 

(10) 

Pregnancy. 

(11) 

Cervicitis. 

(12) 

Carcinoma. 

(13) 

Endometritis. 

(14) 

Tuberculosis. 

(15) 

Masturbation. 

(16) 

Menopause. 

(IT) 

Varices. 

(18) 

ISTeuroses. 

(19) 

Gouty  diathesis. 

(20) 

Eczema. 

SYMPTOMS    AND    DIAGNOSIS    OF    PKURITtTS.  297 

Symptoms  and  Diagnosis. — From  whatever  cause  the  pruritus  arises,  it 
varies  in  intensity  from  a  slight  or  an  occasional  irritation,  mani- 
festing itself  in  sensations  of  an  itching,  pricking,  or  creeping  char- 
acter, all  the  way  to  an  irritation  so  severe  as  to  be  a  continual 
torment,  making  the  day  miserable  and  turning  the  night,  designed  by 
nature  for  rest  and  refreshment,  into  a  curse.  In  such  cases  the  sufferer 
becomes  haggard  and  worn  with  sleepless  nights,  made  hideous  by  the  con- 
stant impulse  to  relieve  the  horrible  itching  by  tearing  at  her  person,  while 
she  longs  for  morning  to  bring  the  activities  of  another  day  to  afford  a  little 
distraction  from  the  Promethean  vulture.  So  intense  is  the  suffering  in  these 
cases  that  the  patient  sometimes  loses  all  self  control  and  leads  an  isolated  life, 
in  order  that  she  may  attend  uninterruptedly  to  the  imperative  demands  of 
the  disease,  which  excite  an  uncontrollable  desire  to  rub  the  affected  parts. 
Cases  have  even  been  known  when,  after  years  of  suffering,  the  patient  has 
committed  suicide  as  the  only  means  of  relief  from  torture.  Those  who  are 
blessed  with  immunity  from  this  dreadful  disease  may  be  thankful  that  they 
know  nothing  of  the  suffering  which  it  entails. 

The  local  changes  in  the  parts  are  characterized  in  the  beginning  by  a 
reddening  of  the  surface  and  then  by  the  appearance  of  small  flat 
papules,  the  skin  over  which  is  speedily  scratched  off.  As  the  disease 
progresses,  the  skin  becomes  thickened  and  white,  while  long  scratch 
marks  are  often  perceptible.  The  vulvar  hairs  to  a  large  extent  disappear,  and 
such  as  remain  are  broken  off  short;  the  parts  are  often  moist  with  secretions. 
Later  on,  the  white  area  increases  in  extent,  and  as  the  skin  thickens,  the  nor- 
mal anatomical  outlines  of  the  parts  disappear.  The  clitoris  is  marked  by  a 
slight  eminence  or  else  disappears  under  a  sort  of  thick  white  blanket,  while 
the  labia  assume  an  almost  pachydermatous  appearance.  When  the  disease  is 
thus  far  advanced,  the  patient,  as  a  rule,  is  almost  beside  herself  with  the 
continuous  desire  to  tear  at  the  parts.  The  changes  in  the  affected  parts  are 
best  described  in  the  words  of  the  dermatologist  as  inflammatory  para- 
keratosis (Veit).  There  is  an  enormous  thickening  of  the  horny  layer  of 
the  epidermis  with  an  extensive  small-celled  infiltration  just  below.  A  pus- 
tular folliculitis  is  sometimes  associated  with  the  original  pruritus,  arising 
from  infection  of  the  parts  irritated. 

Treatment. — In  almost  every  case  of  pruritus  the  suffering  is  so  intense  as 
to  call  for  immediate  relief  of  the  local  condition,  but  the  permanent  cure  can 
only  be  effected  by  the  removal  of  the  underlying  disease.  One  of  the  first 
steps  in  the  treatment  is  a  careful  analysis  of  the  urine,  in  order  to 
discover  a  possible  nephritis  or  diabetes.  It  sometimes  happens  that  itching 
of  the  external  genitalia  is  the  first  symptom  of  sugar  in  the  urine.  If  the 
presence  of  sugar  is  determined,  the  treatment  must,  of  course,  be  directed 
to  the  fundamental  disease ;  nevertheless,  it  is  most  important  to  keep  the  parts 
clean  and  free  from  contamination  by  sponging  them  with  a  rectangular  pad 
of  gauze  wet  with  a  saturated  solution  of  boric   acid    in  water.      Pediculi 


298  PEUKITUS.       VAGINISMUS.       MASTTTKBATIOW. 

or  tlieir  uits  can  always  be  found  by  carefully  examining  the  vulvar  liair>5. 
They  are  readily  destroyed  by  washing  thoroughly  with  green  soap  and 
warm  water  and  then  with  a  decoction  of  fish  berries.  This  pro- 
cedure should  be  repeated  at  intervals  of  a  few  days.  Shaving  the  parts 
is  another  good  method  of  destroying  them,  as  well  as  the  application  of  a 
mixture  of  sweet  oil  and  carbolic  acid  (ten  per  cent).  In  the  case 
of  little  girls  who  complain  of  itching  at  the  vulva,  two  things  should  always 
be  borne  in  mind,  namely,  ascarides  and  uncleanliness.  Ascarides 
are  likely  to  be  associated  with  anal  pruritus,  and  when  this  is  the  case,  an 
examination  of  the  stools  serves  to  clear  up  the  diagnosis  by  revealing  the 
presence  of  the  worms.  The  ova  are  easily  found  in  the  feces,  if  the  worms 
are  at  all  abundant.  Cleanliness  should  be  enforced  by  insisting  upon  the 
gentle  and  careful,  but  thorough  use  of  warm  water  and  pure  castile 
soap  every  few  days.  It  is  a  pernicious  training  which  teaches  children  that 
the  genitalia  should  never  be  touched,  for  the  natural  secretions  are  thus 
allowed  to  accumulate,  causing  irritation  and  congestion. 

Thrush,  growing  in  whitish  patches  on  the  parts,  should  be  removed  by 
a  thorough  cleansing  with  warm  water  and  castile  soap,  followed  by 
dusting  with  dry  powder,  made  according  to  the  following  formula: 

^   Ac.  salic gr.  ij 

Pulv.  camph gr.  jv 

Ac.  borac. 3vj 

Pulv.  amyl 3ij 

j\I.     Ft.  charta. 

S.      Dust  on  with  a  little  pledget  of  cotton  twice  daily, 
after  careful  cleansing. 

A  saturated  solution  of  chlorate  of  potash  in  water  used  as  a  wash 
is  also  a  good  way  of  curing  thrush. 

Sometimes  pruritus  is  excited  and  kept  up  by  a  vaginal  discharge  of  a 
gonorrheal  character.  The  peculiarity  of  a  gonorrheal  discharge,  aside 
from  the  fact  that  its  seat  of  predilection  is  the  vulva,  is  a  tendency  to  invade 
the  cervical  glands  and  provoke  a  ropy,  mucoid,  purulent  discharge,  the  gonor- 
rheal nature  of  which  can  only  be  determined  with  certainty  by  microscopical 
examination.  In  some  cases  of  pruritus,  however,  associated  with  a  tough 
muco-purulent  discharge  from  the  vagina,  an  examination  with  the  microscope 
reveals  the  presence  of  the  yeast  fungus  and  some  of  these  cases  are  associated 
with  gonorrhea;  in  such  cases  the  use  of  permanganate  of  potash  is 
beneficial.  The  application  of  brewer's  yeast  has  also  relieved  the 
difficulty. 

In  questioning  or  examining  a  patient  with  pruritus  accompanied  by  a 
vaginal  discharge,  the  physician  must  remember  that  the  itching  is  more  often 
provoked  by  a  slight  discharge  of  a  thin  quality  than  by  a  profuse  leucorrheal 


TREATMENT    OF    PRURITUS.  299 

one.  A  good  method  of  testing  the  relation  of  the  discharge  to  the  pruritus 
is  to  insert  a  tampon  in  the  vagina  and  leave  it  there  for  twenty-four  hours. 
The  patient  will  often  declare  that  she  has  had  no  itching  at  all,  while  the 
tampon  was  in  place,  which  affords  a  valuable  hint  as  to  the  treatment. 
Dilatation  and  curettage  of  the  uterus  (see  Chaps.  IV  and  VII), 
cauterization  of  the  cervix,  or  the  relief  of  a  vaginitis  (see  Chap. 
XI)  may  in  such  cases  be  followed  by  immediate  relief.  The  physician  must 
not  be  too  sanguine,  however,  as  to  an  immediate  and  permanent  cure.  All 
cases  of  pruritus  should  be  kept  under  observation  and  examined  at  intervals 
of  every  few  weeks  for  a  period  of  several  months. 

Pruritus  limited  to  the  post-menstrual  period  does  not,  as  a 
rule,  call  for  treatment.  If  it  is  severe  enough  to  cause  decided  distress, 
however,  the  physician  need  not  hesitate  to  order  hot  vaginal  douches 
of  a  saturated  solution  of  boric  acid  or  bichloride  of  mercury 
(1:5000). 

If  a  pessary  is  worn  too  long,  it  sometimes  provokes  a  vaginal  discharge 
resulting  in  pruritus;  in  such  a  case  tolle  causam.  et  tollitur  effectus.  When 
the  cause  is  removed  and  a  few  saline  douches  taken,  the  disease  disappears. 
Common  table  salt  in  the  proportion  of  two  teaspoonfuls  to  the  pint  of 
hot  water  makes  a  good  douche. 

We  now  come  to  an  interesting  group  of  cases,  unfortunately  still  a  large 
one,  in  spite  of  the  most  careful  efforts  to  make  a  causal  classification  of  them. 
I  refer,  on  the  one  hand,  to  wdiat  is  known  as  the  neurosis  group  of  cases,  and 
on  the  other,  to  those  advanced  cases  with  extensive  tissue  changes  in  which 
the  original  cause,  whatever  it  may  have  been,  has  long  since  disappeared. 
The  question  of  treatment  in  these  difficult  cases,  which  more  than  all  others 
demand  our  sympathy  and  aid,  is  one  of  peculiar  importance. 

In  the  first  place,  let  me  insist  that  whatever  local  treatment  is  adopted, 
we  must  never  omit  those  powerful  aids,  good  health,  hygiene,  a  well- 
regulated  diet,  daily  baths,  and  tonics.  The  patient  must  take  suf- 
ficient exercise  and  a  sufficient  amount  of  suitable,  non-stimu- 
lating food,  A  cold  bath  in  the  morning  and  a  warm  one  at 
night  with  a  careful  cleansing  of  the  parts  will  aid  greatly  in  the  recovery. 
There  is  no  danger  of  contagion  to  other  persons  through  using  the  common 
bath-tub,  nevertheless,  a  due  regard  to  the  feelings  of  othprs  will  suggest  the 
propriety  of  using  a  separate  sitz  bath  for  cleansing  the  genitals.  While  the 
patient  is  under  observation  an  occasional  mild  hypnotic  should  be  given  to 
secure  a  good  night's  rest  (see  Chap.  VIII).  A  prescription  for  this  purpose 
should,  however,  never  be  put  into  the  patient's  hands,  or  she  will  almost 
surely  abuse  it.  About  once  in  five  days  a  dose  of  chloral,  ten  to  twenty 
grains,  and  sodium  bromide,  grains  forty  to  sixty  in  six  to  eight  ounces 
of  warm  water  may  be  thrown  into  the  rectum  at  bedtime.  Of  the  various 
tonics  and  alteratives,  arsenic  is  the  best.  It  may  be  combined  with  a 
simple  bitter  in  pill  form  as  follows; 


300  PEITEITUS.       TAGIXISMUS.        MASTUEBATIOX. 

1^   Ac.  arseuios gi'-  iro 

Ext.  calumb.  )    __ 

^  ,-   aa 2.T.   1 

Ext.  gent.        )  ^      -• 

M.     Et.  piMa  i.     Mitte  tales  Xo.  100. 

S.       Take  one  pill  after  each  meal. 

In  the  advanced  forms  of  the  disease,  where  there  are  marked  local  changes, 
relief  is  sometimes  afforded  by  painting  the  parts  with  pure  ichthyol. 
After  the  ichthyol  is  applied,  the  patient  must  wear  a  vulvar  pad  to  protect 
the  clothing.  Much  benefit  is  sometimes  secured  by  a  careful  application  to 
all  the  diseased  parts  of  a  ten  per  cent  solution  of  nitrate  of  silver, 
repeated  once  in  every  ten  days  or  longer  (Olshausen).  The  abnormal  insensi- 
bilitv  of  the  parts  is  such  that  the  usual  sensations  of  pain  and  even  of  touch 
are  largely  in  abeyance,  and  this  is  so  marked  that  a  three  to  eight  per  cent 
solution  of  carbolic  acid  in  water  with  a  little  glycerin  and  alcohol 
can  be  borne  without  discomfort  and  much  subsequent  relief.  This  mixture 
may  be  left  in  the  patient's  hands  to  apply  as  she  feels  the  need  of  it.  A  five 
per  cent  carbolic  acid  ointment  made  up  with  lanolin,  according  to 
the  following  formula,  may  be  used: 

^   Pulv.  camph gr.  jv 

Menthol gT.  x 

Ac.  carbolic. .....  =  ....  =  =  .....  gT.  xxv 

Lanolin = ,..,.....  oj 

M.     S.  Ajiply  externally. 

A  small  well-defined  area  of  beginning  pruritus  has  been 
cured  by  treating  it  with  pure  carbolic  acid,  the  application  being  lim- 
ited to  the  spot. 

Cocain    ointment    sometimes  affords  relief. 

I>    Cocain  hydrochl gr.  vj 

Lanolin Bj 

M.     S.  Apply  externally. 

Coating  the  parts  with  cod-liver  oil  gives  temporary  relief.  Xaph- 
thalin  and  anesthesin  in  a  ten  per  cent  solution,  made  up  with  lanolin, 
thoroughly  applied  to  the  parts  has  been  found  useful. 

A  method  of  treatment  in  vogue  at  a  time  when  men  paid  more  careful 
attention  to  the  compounding  of  prescriptions  than  they  do  now,  was  to  put 
the  patient  to  bed  and  bathe  the  parts  with  a  continuous  application  of  a 
zinc    oxide    lotion,    made  according  to  the  following  formiTla : 

^   Zinc,  oxidi    '^ij 

Mist,  acacia^ .5] 

Aq.  rosne 5v 

M.     Et.  lotio.      S.  Tse  externally. 


TREATMENT    OF    PRURITUS.  301 

This  must  be  washed  off  thoroughly  with  a  thin  starch  solution  and 
the  parts  covered  with    benzoated    ointment   (West). 

Scanzoni  recommends  the  use  of  a  solution  of  caustic  potash  in  water, 
about  seven  per  cent,  lightly  applied  with  a  brush,  copious  ablutions  of  cold 
water  being  used  as  the  disease  improves. 

A  hip  bath  of  water  as  hot  as  can  be  borne,  containing  as  much 
sea   salt   as  will  make  it  about  as  strong  as  sea  water,  is  often  of  value. 

C.  Ruge  (Centrhl.  f.  Gyn.,  1896,  vol.  20,  p.  480)  takes  the  positive  posi- 
tion that  pruritus  is  almost  always  of  local  origin,  being  due  to  some  chronic 
or  bacterial  source  of  irritation,  and  that,  therefore,  it  can  almost  without 
exception  be  cured,  even  in  the  worst  cases,  by  a  thorough  cleansing  of 
the  parts.  The  best  way  to  carry  out  Ruge's  suggestions  is  to  put  the 
patient  under  an  anesthetic,  and  after  shaving  the  parts,  to  remove  all  the 
epidermis  which  will  come  off  without  exciting  hemorrhage,  by  means  of  a 
scrubbing  brush  and  soap. 

T'laischler,  following  the  same  idea,  recommends  applying  a  twenty  per 
cent  solution  of  nitrate  of  silver.  In  one  case  he  gave  complete  relief 
by  using  a  fifty  per  cent  solution. 

A  ten  per  cent  thymol  salve  (Gottschalk)  is  a  valuable  remedy  for  the 
relief  of  the  itching. 

R   Thymol 10  parts 

Ung.  petrolat 100       " 

M.      S.  Apply  externally. 

Soaking  the  parts  in  a  one  per  cent  solution  of  nitrate  of  silver  for 
hours  at  a  time  is  sometimes  of  great  assistance  in  producing  a  permanent 
alteration  for  good  in  the  condition  of  the  parts. 

C.  D.  Meigs  described  a  case  which  he  considered  was  due  to  a  trichiasis 
of  the  vulva.  He  found  that  the  hairs  springing  from  the  margin  of  the 
mucous  membrane  were  pouting  inwards,  so  as  to  irritate  the  membrane  and 
occasion  the  most  distressing  itching.  When  these  were  removed  the  pruritus 
disappeared. 

I  have  found  much  relief  attended  the  use  of  a  lotion  of  lead  water 
and    laudanum   made  up  with  lime  water  instead  of  plain  water. 

^   Liq.  plumb,  subacet f3ij 

Tine,  opii f 3ij 

Liq.  calcis    fovj 

M.      S.   Apply  externally. 

Another  remedy  which  often  gives  relief  is  a  two  per  cent  carbolic  acid 
poultice.  I  have  used  cherry  laurel  water  with  great  satisfaction  (Aq. 
lauro.  cerasi),  when  the  genuine  article  can  be  secured.  The  following  pre- 
scriptions for  topical  applications  are  given  by  Goodell: 


302  PEUEITTJS.       VAGINISMUS.       MASTUKBATIOIT. 

^   Cbloralis 


„         ,  I    aa oiv 

Campnorse  ; 

Rub  into  oil  and  add : 

Ung.  simplicis 5] 

Pulv.  ac.  borac Sjv 

M.      S.  Apply  externally. 

^   Ac.  acetici 5] 

Glycerina? oii] 

M.      S.  Apply  externally. 

^   Sod.  borat 5ij 

Morpb.  mnriat gT.  xx 

Ac.  bydrocyan.  dil f3j 

Glycerine   f oj 

Aq.  rosse  ad fovii] 

M.      S.  Apply  externally  T^'itb  a  pledget  of  cotton. 

For  pruritus  of  diabetic  origin,  Goodell  speaks  most  bigbly  in 
favor  of  tbe  following  formula,  used  by  Dr.  James  Simpson  of  Pbiladelpbia, 
namely,  fifteen  grains  of  tbe  salicylate  of  soda,  in  glycerin,  given 
by  tbe  moutb  every  four  bours. 

Scbleicb's  solution  (see  p.  277)  injected  into  tbe  mons  veneris  bas 
been  found  beneficial  in  some  cases.  I  sbould  be  inclined  to  extend  tbe  use 
of  tbis  injection  to  tbe  ilio-inguinal  and  genito-crural  nerves  above  and  tbe 
perineal  nerves  below. 

Tbe  use  of  tbe  galvanic  current  bas  been  followed  by  brilliant  results  in 
some  cases  in  tbe  bands  of  several  autborities.  Cbolmogoroff  {Cenirhl.  f, 
Gyn.,  1891,  vol.  15,  p.  612)  cites  an  instance  wbere  be  cured  a  severe  case  of 
two  vears'  standing  in  six  applications.  Tbe  metbod  of  application  is  as 
follows : 

Tbe  positive  pole  (anode)  is  introduced  into  tbe  vulva  at  tbe  vaginal  ori- 
fice, wbile  tbe  negative  pole  (katbode)  is  carried  by  means  of  cotton  wet  witb 
salt  solution  all  over  tbe  affected  parts.  Tbe  sitting  sbould  last  from  ten  to 
fifteen  minutes.  Tbe  patient  sbould  take  tbe  current  as  strong  as  sbe  can 
comfortably  bear.  H.  von  Campe  also  cured  a  bad  case  of  five  years'  standing 
by  tbis  metbod  {CentrU.  f.  Gyn.,  1887,  voL.ll,  p.  521). 

Tbe  X-ray  may  be  tried  in  tbe  treatment  of  pruritus,  but  its  value  bas 
not  yet  received  clinical  confirmation. 

If  cleansings  (Euge),  batbs,  topical  applications,  •  and  galvan- 
ism, employed  wbile  tbe  cause  of  the  affection  is  being  sougbt  for,  do  not 
succeed  in  relieving  a  distressing  case  of  pruritus  witb  extensive  cbanges, 
it  is  best  to  resort  to  surgery  and  excise  all  tbe  diseased  tissues, 
cutting  away  tbe  clitoris,  tbe  nympbse,   and  tbe  adjacent  parts  of  tbe  labia 


TREATMENT  OF  PRURITUS  IK  PREGNANCY.  303 

majora  in  the  form  of  an  inverted  A,  drawing  the  remaining  tissues  inward, 
and  attaching  them  to  the  mucosa  at  the  vaginal  orifice. 

Hirst  (Amer.  Med.,  May,  1903,  p.  Y85)  cured  a  case  by  excising  the 
nerves  going  to  the  parts,  after  exposing  them  by  making  four  incisions, 
two  in  the  groins  and  two  in  the  buttocks.  It  is  not  within  the  scope  of  my 
present  purpose,  however,  to  do  more  than  indicate  the  value  of  surgery  as  a 
last,  but  most  helpful  resource. 

Pruritus  in  Pregnancy. — There  is  one  special  form  of  pruritus  which  occurs 
in  pregnancy  and  is  peculiarly  distressing.  It  usually  appears  in  the  later 
months  and  the  patient  complains  of  the  most  distressing  sensations  of  heat, 
swelling,  and  itching  of  the  parts.  An  examination  shows  the  external  genitals 
red  and  swollen  and  often  excoriated  by  scratch-marks.  The  vagina  also  is 
swollen,  and  covered  with  a  curdy  white  discharge.  It  is  the  association  with 
a  vaginal  aifection  which  distinguishes  this  form  of  pruritus  from  other  varie- 
ties. The  condition  comes  to  an  end  with  the  termination  of  pregnancy,  but 
it  is  often  difficult  to  cure  before  its  natural  terminus  is  reached.  The  patient 
should  be  kept  quiet  and  use  a  hot  permanganate  douche  (one  to  three 
per  cent)  two  or  three  times  a  day.  Bathing  with  equal  parts  of  alcohol  and 
water  is  of  service,  to  which  may  be  added  sufficient  coca  in  to  make  a 
one  to  two  per  cent  solution.  If  the  itching  persists  in  spite  of  mild  local 
treatments,  the  patient  may  be  put  into  the  knee-breast  posture  and,  after 
the  vagina  is  exposed  through  a  large  cylindrical  speculum,  it  is  everywhere 
swabbed  out  with  a  five  per  cent  solution  of  nitrate  of  silver.  This 
treatment  will  bring  away  a  superficial  cast  of  the  vagina  in  the  course  of  a 
few  days.  After  three  days  the  douche  treatment  may  be  resumed,  until  the 
vagina  appears  normal.  Ashwell  recommends  the  following  prescription  of 
Meigs,  using  the  language  of  the  latter  in  doing  so,  "  having  been  a  great 
many  times  consulted  for  the  relief  of  pruritus  vulvae  and  most  frequently  by 
pregnant  women,  I  have  rarely  had  occasion  to  order  anything  more  than  the 
following  formula,  namely: 

^   Sod.  biborat §ss. 

Morph.  sulph gr.  vj 

Aq.  rosse  dest Sviij 

M.  S.  Apply  three  times  a  day  to  the  affected  parts  with 
a  piece  of  lint,  after  washing  with  tepid  water 
and  soap  and  carefully  drying  the  parts. 

In  the  worst  forms  of  the  affection  it  has  been  found  necessary  to  termi- 
nate   pregnancy. 


304  PEUKITUS.       VAGINISMUS.       MASTURBATION. 


VAGINISMUS. 

Definition. — Vaginismus  is  an  affection  first  named  and  fully  described  hj 
Marion  Sims.  It  is  cliaracterized  by  violent  reflex  spasmodic  con- 
tractions of  tlie  muscles  around  the  entrance  of  the  vagina,  namely,  the 
sphincter  vaginae,  the  levator  ani,  the  transverse  perinei,  and  the  adductors  of 
the  thighs.  This  condition  of  muscle  spasm  is  called  forth  either  by  an  attempt 
at  coitus  or  the  effort  to  make  an  examination  of  the  vagina. 

It  is  a  disease  of  married  life  and  for  the  most  part  of  young  women,  per- 
sisting sometimes  for  many  years.  Sims,  whose  descriptions  of  it  are  unsur- 
passed in  clearness,  says :  "  By  the  term  vaginismus  I  mean  an  excessive  hyper- 
esthesia of  the  hymen  and  vulvar  outlet,  associated  with  such  involuntary 
spasmodic  contractions  of  the  sphincter  vaginse  as  to  prevent  coition.  This 
irritable  spasmodic  action  is  produced  by  the  gentlest  touch ;  often  the  touch  of 
a  camel's  hair  brush  will  produce  such  agony  as  to  cause  the  patient  to  shriek, 
complaining  at  the  same  time  that  the  pain  is  that  of  thrusting  a  knife  into  the 
sensitive  part.  In  a  very  large  majority  of  cases  the  pain  and  spasm  conjoined 
are  so  gTeat  as  to  preclude  the  possibility  of  sexual  intercourse.  In  some  in- 
stances it  will  be  borne  occasionally,  notwithstanding  the  intolerable  suffering, 
while  in  others  it  is  wholly  abandoned,  even  after  the  act  has  been  repeatedly, 
as  it  were,  perfectly  performed." 

The  spasm  of  the  muscles  about  the  vaginal  orifice  varies  with  different 
patients,  all  the  way  from  a  distress  which,  though  severe,  can  be  endured  and 
with  great  difiiculty  overcome,  by  a  woman  who  is  determined  to  submit  to  her 
wifely  obligations,  to  the  most  uncontrollable  apprehension  and  agonizing  pain. 
The  area  of  sensitiveness  in  vaginismus  is  situated  about  the  urethra,  the 
hymen,  and  especially  the  posterior  commissure,  from  which  it  extends  over 
the  entire  vulva.  In  some  cases  there  are  manifest  changes  at  the  orifice  in  the 
form  of  exquisitely  tender  deep  red  spots ;  fissures  may  also  be  found  in  the 
vulva,  resembling  painful  fissures  of  the  anus. 

A  picture  of  vaginismus  is  sometimes  seen  in  the  examining  room,  when 
the  physician,  perhaps  with  large  fingers  and  clumsy  efforts,  attempts  to  force  the 
digit  through  the  vulva  and  hymen  in  his  efforts  to  penetrate  the  vagina.  The 
mucosa  at  the  vaginal  orifice  is  naturally  delicate  and  sensitive,  and  it  is  capable 
of  acquiring  an  extraordinary  degTee  of  sensibility  through  the  attitude  of  ex- 
pectancy, whether  of  pleasure  or  of  pain.  This  shrinking  and  supersensitiveness 
constitute  one  of  the  safeguards  of  young  womanhood  before  the  maturation  of 
the  sexual  function. 

Etiology. — As  a  rule,  the  vaginismus  is  present  from  the  first  attempt  at 
coitus  and  acts  as  an  insuperable  barrier,  so  that  when  the  parts  are  examined 
by  a  physician,  the  hymen  is  found  intact.  In  some  cases,  however,  intromis- 
sion is  occasionally  successful  and  the  vaginal  orifice,  when  examined  under  an 


ETIOLOGY    OF    VAGINISMUS. 


305 


anesthetic,  presents  no  abnormality.  It  is  noteworthy  that  vaginismus  is  rarely 
present  among  the  poor,  while  it  is  often  seen  in  the  hypersensitive  women  of 
the  leisure  classes  with  neuropathic  constitutions.  Masturbation  has  been 
assigned  as  a  cause  in  some  cases. 

Vaginismus  may  be  the  consequence  of  a  gonorrheal  infection.  It  is 
sometimes  due  also  to  some  degree  of  male  impotence,  whereby  the  rela- 
tionship is  not  fully  consummated  at  first.  The  element  of  anxiety  and  uncer- 
tainty associated  with  ill-directed  efforts  on  the  part  of  the  husband  is  not 
without  its  effect  upon  his  co-respondent  wife.  The  lihedo  sexualis,  which  nor- 
mally obtunds  and  renders  transitory  the  natural  pain  of  the  first  cohabitation, 
disappears,  and  an  attitude  of  anxious  expectancy  takes  its  place,  which,  in 
time,  is  converted  into  apprehension  and  abhorrence,  so  that  instead  of  grati- 
fication, the  wife  feels  disgust,  and  instead  of  pleasure,  pain. 


Fig.  80. — A  Urethkal  Gakunclk  Rkskmbling  a  Small  Dakk  Hematoma  Springing  from  the  Right, 
Posterior  Margin  of  the  Urethra.  On  closer  examination  it  is  seen  to  be  an  intensely  injected 
tumor  springing  from  the  mucosa.     It  is  usually  sessile  and  often  extends  upward  into  the  urethra. 

21 


306  PKTJKITUS,       VAGINISMUS,       MASTUEBATIOlSr. 

There  is  a  urethral  form  of  the  disease  which  I  would  associate 
with  a  gonorrheal  infection,  in  which  the  meatus  urinarius  is  swollen,  red, 
everted,  and  exquisitely  tender.  The  pain  on  contact  is  fully  equal  to  that 
induced  by  a  urethral  caruncle.  Here  the  vaginal  orifice  and  all  the  surround- 
ing parts  can  be  freely  touched,  provided  only  the  urethra  is  let  alone;  while 
any  contact  with  or  attrition  of  the  urethra  provokes  a  violent  and  utterly  un- 
bearable pain. 

Sometimes  when  the  parts  at  the  vaginal  orifice  are  exquisitely  sensitive 
and  the  patient  shrinks  from  the  slightest  and  gentlest  contact,  shrieking  when 
the  finger  im]3inges  upon  the  j)arts,  the  whole  trouble  will  prove  to  arise  from  a 
cause  of  no  greater  significance  than  a  urethral  caruncle  (see  Fig.  80). 
The  true  caruncle  is  a  deep-red,  well-defined,  vascular  tumor  projecting  from 
one  side  of  the  urethra  and  often  flattened  like  a  cockscomb  or,  when  sessile, 
a  mulberry  mass.  A  little  minute  observation  will  distinguish  this  well-defined 
tumor  from  the  general  reddening  and  swelling  of  the  meatus  just  described. 

Occasionally,  vaginismus  is  seen  in  a  physically  ill-matched  pair,  that  is  to 
say  a  little  woman,  childlike  in  both  person  and  temperament,  wedded  to  a  man 
of  large  frame  with  insistent  sexual  desires.  Here,  where  the  manifest  dispro- 
portion of  body  is  carried  into  a  like  absence  of  correlation  in  the  sexual 
organs,  great  distress  may  be  occasioned  by  the  marital  approach,  ending  in  a 
condition  of  general  hysteria  with  a  well-marked  vaginismus.  This  explanation 
of  vaginismus,  as  being  due  to  disproportion  between  the  intromittent  organ  and 
the  receptive  channel,  is  one  which  appeals  to  the  lay  imagination  as  the  great 
common  factor  in  producing  the  disease.     It  is,  however,  extremely  rare. 

Another  cause  of  vaginismus,  more  frequently  noted,  is  the  displacement  of 
the  fourchette  and  the  orifice  upwards  and  forwards,  making  the  channel  difii- 
cult  of  access,  and  rendering  the  urethra  and  clitoris  liable  to  injury  from  too 
frequent  forcible  impacts. 

Prognosis. — The  prognosis  as  to  recovery  in  vaginismus  when  left  alone  is 
bad.  Pregnancy  is  rare  under  the  circumstances;  nevertheless,  it  may  take 
place,  and  when  this  is  the  case  the  vaginismus  is  usually  relieved,  though  not 
necessarily  so.  Sims  cites  a  remarkable  instance  in  which  the  family  physician 
anesthetized  the  wife  for  the  first  coitus,  which  then  offered  no  difficulty;  he 
continued  to  do  this  at  bi-weekly  intervals  for  a  year,  when  she  became  preg- 
nant and  bore  a  child  at  term.  The  old  pain  returned,  however,  and  it  became 
necessary  to  resume  the  "  ethereal  relations."  Sometimes  the  distressed  and 
suffering  wife  secures  an  immunity  from  any  approach  and  lives  from  year  to 
year  as  in  her  maidenhood,  a  virgo  intacta. 

Treatment. — Every  case  of  vaginismus  must  be  taken  seriously  and  faith- 
fully treated  until  a  permanent  recovery  is  assured.  The  first  step  is  to  secure 
for  the  wife  rest  and  freedom  from  importunity.  If  she  is  subjected  to  con- 
tinual approaches  and  submits  to  frequent  ineffectual  attempts  to  overcome  the 
difficulty  by  the  natural  method,  the  nervous  system  often  breaks  down  and 
she  becomes  a  physical  and  mental  wreck.     In  order  to  secure  the  quiet  which 


TREATMENT    OF    VAGINISMUS.  .  307 

she  needs,  she  must  sleep  alone ;  some  sedative  should  be  given  for  a  few  days  at 
the  beginning  of  the  treatment  to  secure  a  habit  of  sleep.  It  is  most  important 
to  keep  up  a  hygienic  regimen  by  using  daily  cold  baths  or  spongings,  as  well  as 
early  rest  and  exercise  each  day,  according  to  the  needs  of  the  individual  case. 

The  active  treatment  of  a  vaginismus  begins  with  the  effort  to  discover  some 
well-defined  local  cause  which  can  be  removed.  As  a  rule,  it  is  impossible  to 
make  a  thorough  examination  in  the  usual  manner  on  the  office  table.  The 
patient,  with  the  best  will  in  the  world,  involuntarily  draws  her  thighs  to- 
gether, and  even  if  the  examiner  by  dint  of  persuasion  and  great  difficulty  suc- 
ceeds in  introducing  a  well-oiled  finger  he  has  accomplished  nothing.  It  is  best 
then  to  insist  upon  a  complete  examination  under  anesthesia  at  the  outset,  secur- 
ing permission  to  remove  any  minor  cause  of  the  trouble  which  may  be  found  at 
the  same  time.  Careful  inquiry  must  be  made  beforehand  as  to  the  potency  of 
the  husband  and  as  to  any  history  of  gonorrhea.  Nitrous  oxide  gas  wdll  not 
suffice  to  induce  the  necessary  relaxation ;  ether  or  chloroform  must  be  used. 

The  vulva  is  examined  for  signs  of  inflammation,  fissures,  or 
red  spots.  The  condition  of  the  urethra  is  noted  as  to  whether  it  is  swol- 
len, red,  or  everted.  A  urethral  caruncle,  if  present,  must  be  treated 
according  to  the  following  method:  (1)  it  must  be  thoroughly  removed  down 
to  and  beyond  its  base;  (2)  this  may  be  done  under  cocain  anesthesia  (ten  per 
cent),  by  laying  a  pledget  of  cotton  saturated  with  the  drug  on  the  growth  for 
ten  minutes;  (3)  when  the  growth  is  pedunculate,  it  may  then  be  grasped, 
drawn  forward,  transfixed,  tied  both  ways,  and  then  cut  off  well  beyond  the 
ligature.  The  removal  of  a  sessile  growth  is  a  delicate  piece  of  plastic  work, 
and  the  physician  would  do  wisely  in  such  a  case  to  consult  a  specialist.  Any 
fissures  or  little  superficial  ulcerations  surrounded  by  an  intensely  red  area 
near  the  hymen  are  noted.  The  hymen  itself  is  observed,  to  ascertain  whether 
it  is  intact,  and  whether  inflamed  or  not.  The  vagina  and  the  cervix  uteri  are 
examined  for  evidences  of  gonorrhea.  It  is  a  good  plan  to  dilate  the  cervix  in 
order  to  facilitate  pregnancy.  If  gonorrhea  is  found,  an  effort  may  be  made  to 
wipe  it  out  at  once  by  using  a  strong  (thirty  per  cent)  solution  of  nitrate  of 
silver,  carefully  applied  to  all  the  affected  parts.  A  gonorrheal  urethritis  is 
also  well  treated  by  repeated  applications  of  a  two  to  three  per  cent  solution  of 
silver. 

If  the  case  is  not  extreme,  two  remedies  may  be  tried :  first,  putting  a 
pledget  of  cotton  saturated  with  a  ten  per  cent  solution  of  cocain  at  the 
vaginal  orifice  for  ten  minutes  and  removing  it  just  before  coitus;  secondly, 
the  immediate  application,  upon  removing  the  cocain,  of  a  quantity  of  vaselin 
to  the  parts.     If  this  plan  works  well,  it  can  be  repeated. 

In  simple  cases,  that  is  to  say  cases  w^here  there  is  no  inflammatory  basis  and 
no  inflammation  has  been  superadded,  the  use  of  the  galvanic  current  has 
succeeded  in  several  instances  in  effecting  a  complete  cure.  Lomer  (Centrhl. 
f.  Gyn.,  1889,  vol.  13,  p.  8Y0)  cites  a  case  lasting  five  years  and  associated  with 
frequent  involuntary  perineal  contractions,  in  which  he  used  a  weak,  barely 


308  PETJEITUS.       VAGIIiriSMUS.       MASTTTKBATION. 

perceptible  galvanic  current  every  two  or  three  days  for  four  or  five  min- 
utes at  a  time.  In  six  weeks  the  patient  was  completely  cured  and  had  had  no 
return  of  the  trouble  at  the  end  of  six  months.  Another  similar  case  was  cured 
by  him  in  like  manner.  In  both  cases  there  was  dysmenorrhea,  which  was  also 
relieved  to  some  extent  by  the  treatment. 

If  inflammatory  areas  or  fissures  are  found  in  the  neighborhood 
of  the  vaginal  outlet  they  should  be  dissected  out  in  a  linear  manner  and  the 
mucosa  carefully  brought  together  with  a  fine  catgnit  suture. 

When  no  evident  cause  is  found,  or  when  the  hymen  is  intact  or  deeply  red- 
dened, no  plan  which  has  yet  been  devised  is  equal  to  that  of  Marion  Sims, 
namely,  removal  of  the  hymen,  the  incision  of  the  vaginal  ori- 
fice, and  the  subsequent  dilatation  of  the  orifice.  The  patient  is  pro- 
foundly anesthetized  and  the  parts  cleansed,  after  which  the  hymen  is  seized 
on  one  side  anteriorly  by  a  pair  of  rat-toothed  forceps  and  pulled  out,  being 
excised  at  the  same  time  well  down  to  its  base  in  one  continuous  piece  on 
the  right  and  left  sides  posteriorly.  "When  this  has  been  done  it  was  Sims' 
custom  to  pass  two  fingers  into  the  vagina  to  stretch  the  outlet  and  then  to 
make  a  deep  cut  in  each  sulcus  about  two  inches  long,  united  at  the  raphe, 
and  prolonged  in  the  form  of  a  Y  quite  down  to  the  perineal  integument.  Each 
cut  was  about  half  an  inch  or  more  above  the  sphincter  vaginae,  half  an  inch 
over  its  fibres,  and  an  inch  from  its  lower  edge  to  the  perineal  raphe.  These 
operations  were  then  followed  by  the  insertion  of  a  bougie  or  a  dilator  three 
inches  long  and  an  inch  and  a  half  in  diameter  in  order  to  stretch  the  opening. 
This  was  worn  for  two  hours  in  the  morning  and  t^vo  or  three  in  the  afternoon 
for  a  period  of  two  or  three  weeks.  The  bougie  is  of  conical  form  and  open  at 
its  outer  end,  with  a  depression  for  the  urethra. 

The  plan  of  having  the  patient  repair  to  the  physician's  ofiice  regTilarly  for 
the  purpose  of  having  him  stretch  the  outlet  by  the  insertion  of 
specula  of  successively  larger  sizes  does  not  seem  to  be  worth  trying, 
from  the  experience  of  many  persons,  though  it  suggests  itself  as  useful. 

Veit,  who  has  made  a  most  careful  study  of  the  treatment  of  vaginismus, 
has  given  up  the  excision  of  the  hymen  to  a  large  extent  in  favor  of  two  radi- 
ating incisions,  cutting  through,  not  only  the  hymen  but  the 
sphincter  vaginae  as  well.  Then,  to  check  the  hemorrhage,  the  wound  is 
closed  with  superficial  and  deep  sutures  of  the  vulva,  passed  in  the  same  direc- 
tion, and  attaching  the  vagina  to  the  vulvar  mucosa.  Veit  uses  interrupted  silk 
sutures  and  removes  them  in  ten  days,  after  applying  cocain.  The  effect  of  such 
an  operation  is  to  convert  the  nulliparous  outlet  into  the  shape  of  a  parous  one. 
After  recovery  from  this  operation,  the  outlet  is  habituated  to  the  passage  of 
tubular  specula,  increasing  in  size,  imder  cocain  anesthesia.  Finally,  when  the 
patient  can  stand  the  introduction  of  a  speculum,  three  centimetres  in  diameter, 
without  cocain  and  without  the  use  of  any  lubricant,  she  is  discharged  as  cured. 
Veit  insists  that  the  important  point  in  this  treatment  lies  in  the  after  manage- 
ment of  the  case. 


GBNEBAL    COJNTSIDEKATIONS    ON    MASTUKBATION.  309 


MASTURBATION   IN   WOMEN. 

General  Considerations.' — A  strong  instinct  of  repugnance  impels  us  to  gloss 
over  this  section  of  preventive  gynecology,  and  to  revolt  when  sacrilegious  hands 
are  laid  on  our  ideal  of  purity.  But  the  family  practitioner  is  under  obligation 
to  see  that  the  mother  warns  and  watches  her  growing  girl;  he  may  no  longer 
ignore  the  prevalence  of  the  danger ;  he  must  recognize  the  marks  of  the  yield- 
ing to  this  temptation  in  time  to  help ;  and  he  cannot  avoid  some  study  of  auto- 
erotism in  women  if  he  would  give  effective  counsel  at  critical  periods.  In  a 
restricted  space  conclusions  only  can  be  given.  Reversing  the  usual  order,  how- 
ever, the  common  degrees  of  the  habit  among  ordinary  individuals  will  receive 
attention  rather  than  the  rarer  excesses  of  the  unbalanced.  Yet  these  lesser 
troubles  are  the  more  difficult,  since  there  is  no  recess  in  the  world  so  truly 
impenetrable  as  that  chamber  of  the  adolescent's  mind  where  she  hides  her 
questioning  concerning  the  vague  stirrings  of  love  and  sex-consciousness.  If 
we  start  with  the  proposition  that  some  curiosity  about  the  awakening  genital 
sensations  of  puberty  is  normal,  and  some  pressures  and  frictions  instinctive, 
then  we  may  fairly  consider  restriction  of  such  experimentation  a  stage  of  ad- 
vance, and  entire  freedom  from  contacts  a  high  degree  of  self-control.  Animals 
in  youth  and  in  the  periods  of  sexual  excitement  exercise  such  practice ;  in  some 
tribes  low  in  the  scale  it  is  universal  among  the  women;  in  the  Orient  and  in 
ancient  times  there  has  been  the  uttermost  openness  of  excess.  Such  primitive 
instincts,  often  reinforced  by  neurotic  heredity  and  a  will  little  trained  in  self- 
control,  leads  the  child  directly  toward  trial  of  these  excitements. 

Boys  teach  each  other  this  vice  more  often  than  girls  do.  The  muscular 
activities  of  the  young  male,  and  the  traditions  of  the  hurtfulness  of  excess, 
make  for  moderation,  whereas  the  secretiveness  of  the  girl  lessens  the  chances 
of  detection  or  confession  of  a  solitary  indulgence  that  is  self-taught.  Among 
the  crowded  poor  and  the  ignorant  foreign  population  evil  communications  are 
facile.  But  in  any  individual,  in  adolescence,  the  soil  is  fertile,  with  its  emo- 
tional and  affectional  fervors  and  introspective  intensities.  "  These  years  are 
sensitive  to  all  matters  pertaining  to  sex,  even  very  remotely,  to  a  degree  about 
which  the  ordinary  parent  is  densely  ignorant  and  optimistic."  It  should  not 
surprise  us  then,  if,  in  the  common  absence  of  all  instruction,  and  in  the  pres- 
ence, let  us  say,  of  some  pelvic  disturbance,  the  habit  were  often  started.  Add 
to  the  monthly  rush  of  blood  to  the  genitals,  the  friction  of  the  napkin,  the 
suggestiveness  of  the  hot-water  bag,  the  lying  awake  in  day  dreams  in  bed  the 
iirst  day  of  the  period,  and  we  may  well  fear  such  arousing  at  some  time  during 
the  seventy  periodical  opportunities  between  puberty  and  nubility. 

The  danger  zones  are  these :  Infancy ;  puberty  and  the  years  immediately 
following ;  school  and  factory  life  ;  engagement ;  marital  maladjustment ;  widow- 
hood; the  pre-climacteric  sexual  activity;  and  any  long  period  of  nervous  in- 


310  PEUEITUS.       VAGI^'ISMUS.        ilASTUEBATIO]!?'. 

tensity  or  breakdown.  Hare  before  puberty,  the  usual  time  of  beginning  is 
just  afterward,  and  the  average  time  of  excess  is  within  the  next  four  years. 

General  Causes. — Parents  who  are  intemperate,  whether  through  weakness  of 
will  or  excess  of  passion,  transmit  such  tendencies.  Among  neurasthenics  more 
than  half  hare  been  masturbators  at  some  time,  and  the  most  pronounced  cases 
are  very  generally  found  among  them.  The  two  great  main  causes,  however, 
are:  defective  education,  and  its  result,  defective  seK-control.  Ignorance  of  the 
simplest  sex  knowledge,  infirmity  of  body,  absence  of  absorbing  and  healthful 
occupation,  insufficient  out-door  exercise,  lack  of  a  constant  stream  of  elevating 
influences  and  stimuli — all  these  favor  the  habit,  particularly  where,  as  in  cer- 
tain natures,  there  is  capacity  for  an  overplus  of  sexual  passion.  Among  the 
most  potent  factors  are  undoubtedly  these  three :  Emotional  excesses,  when  feel- 
ing fails  to  be  translated  into  action,  whether  it  be  roused  to  frequent  intensity 
by  novel,  or  theatre,  or  sermon;  self-indulgences,  such  as  late  rising,  and  all 
idleness,  sulky  reticence,  and  hysterical  outbreaks ;  and  intimacies  of  the  person, 
whether  the  liberties  be  with  other  girls,  or  with  boys  and  men. 

Local  Causes. — Irritation  frcmi  lack  of  cleanliness  is  found  not  alone  among 
the  tubless.  The  fastidious  not  infrequently  fail  to  clean  the  space  beneath  the 
prepuce  and  the  interlabial  grooves.  Vulvitis,  eczema,  parasites,  leucorrheal 
discharges,  and  highly  acid,  concentrated,  or  diabetic  urine  bring  about  irri- 
tations and  scratching.  Ill-fitting  clothing  may  also  do  so.  Rectal  worms,  anal 
fissure,  and  chronic  constipation  are  some  of  the  causes  of  congestion  and  itch- 
ing. All  pelvic  disorders  whatever,  and  particularly  ovarian  irritations,  draw 
the  attention  to  these  sensations,  and  such  inflammations  and  displacements  con- 
stitute the  most  important  of  the  local  causes. 

Prevalence. — We  have  no  means  of  estimating  the  frequency  either  of  minor 
degrees  of  self-abuse  or  its  occurrence  among  healthy  individuals.  Among  boys 
"  whenever  careful  researches  have  been  undertaken,  the  results  are  appalling 
as  to  prevalence."  For  women  of  loose  life  and  certain  peasants  there  are  fig- 
ures showing  a  very  frequent  occurrence.  Among  women  of  a  good  class  there 
are  some  indications  that  it  is  by  no  means  uncommon,  as  for  instance,  where 
one  thousand  consecutive  gynecological  cases  showed  well-marked  vulvar  hyper- 
trophies in  over  one-third.  By  one-third  of  this  third,  full  admission  was  made, 
so  that  it  is  fair  to  attribute  the  findings  in  the  remainder  to  the  same  cause, 
especially  as  categorical  denial  was  forthcoming  in  only  one  in  fifty.  The  above 
figures  bear  only,  however,  on  women  with  pelvic  disorders,  in  whom  more  or 
less  chronic  attention  to  the  sex  organs  has  been  necessarily  present.  On  all 
sides  of  such  questions  one  must  beware  of  exaggeration.  "  The  difference," 
says  the  astute  Dooley,  "between  Christyan  Scientists  an'  doctors  is  that 
Christy  an  Scientists  think  they'se  no  such  thing  as  disease,  an'  doctors  think 
there  ain't  annythin'  else." 

It  cannot  be  too  strongly  stated  that  in  a  very  large  proportion  of  instances 
of  masturbation  in  women  the  matter  is  a  physical  rather  than  a  sexual  one. 
It  might  be  said  to  be  sexless.    By  this  is  meant  that  sensual  images  and  desires 


METHODS    OF    MASTUKBATIOK.  311 

are  infinitely  less  often  consciously  associated  with  the  practice  in  women  than 
in  men.  The  distinction  applies  particularly  to  the  intelligent  classes.  Among 
refined  and  delicate  women,  the  pent-np  sex  hunger  may  take  this  outlet  without 
recognition  of  the  real  meaning  of  the  impulse,  and  nothing  is  more  astounding 
on  the  part  of  clear  minds,  than  the  failure  to  make  the  connection  between 
their  knowledge  of  physiology  and  social  practices  and  their  genital  sensations. 
Aversion  to  men  is  not  uncommon  in  association  with  it. 

Methods. — In  infants  the  means,  in  nearly  all  instances,  is  thigh  compres- 
sion, the  child  being  seated,  and  swaying  its  body  until  flushing  and  excitement 
and  staring  end  in  the  deep  breathing  of  the  climax.  In  the  worst  cases  the 
thigh  rubbing  is  almost  incessant  during  the  waking  hours.  At  this  age  the 
practice  is  far  more  commonly  seen  in  girls  than  in  boys.  In  girls  of  four  or 
five  manual  friction  of  the  prepuce  is  the  method.  Tell-tale  hypertrophy  of 
longitudinal  folds  and  the  frequent  pigmentation  often  render  the  habit  easy 
to  recognize  in  an  early  stage. 

After  puberty  the  habit  may  be  mental,  vulvar^  vaginal,  urethral,  mam- 
mary, or  any  combination  of  these.  The  fifth  is  presumably  rare,  but  the 
occasional  hypertrophies  and  pigmentations  about  the  nipple  point  to  breast 
congestion  as  a  feature  of  some  cases.  The  psychic  form  of  solitary  sexual 
indulgence  is  most  difiicult  of  all  to  study  or  describe,  its  shadings  are  so  various, 
its  ignorances  of  actuality  so  colossal.  Vaginal  masturbation  is  rare  because 
of  the  fear  of  harming  the  hymen  and  thus  destroying  virginity. 

The  usual  vulvar  method  is  digital  pressure,  applied  to  the  labia  minora, 
or  to  the  prepuce.  To  and  frO  sliding  of  these  parts,  hard  pressed  against  the 
symphysis  and  descending  rami  of  the  pubes,  or  forward  and  backward  over  the 
edge  of  the  subpubic  arch,  produces  nerve  excitation  and  alternate  filling  and 
emptying  of  the  cavernous  structures  of  the  bulbs  of  vestibule,  clitoris  and 
labia.  That  the  labia  minora,  which  in  their  structure  can  be  truly  called 
erectile,  are  the  most  common  point  of  attack,  is  shown  by  their  being  the  most 
frequent  seat  of  hypertrophy,  while  enlargement  of  the  clitoris  is  distinctly 
unusual — perhaps  because  its  make-up  does  not  admit  of  the  same  acute  edemas. 

Pressure  with  the  thighs  seems  as  effective  in  producing  enlargement  as 
manualization.  While  sitting  with  crossed  thighs,  a  slight  bending  forward  of 
the  trunk  brings  the  vulva  against  the  seat  of  the  chair,  and  rhythmic  adductor 
action  produces  the  orgasm.  In  highly  sensitive  states  the  adductor  rhythm 
alone  is  sufficient,  and  this,  at  times,  without  motion  evident  to  any  onlooker. 
Indeed,  the  extent  of  the  need  of  watchfulness  can  never  be  grasped  unless  it  is 
known  that  when  self-abuse  has  reached  its  keenest  pitch  in  certain  individuals 
the  effective  pressures  or  frictions  are  so  simple  that  a  girl  can  reach  the  climax 
in  bed  with  her  mother  without  suspicion.  A  roll  of  bedclothes  or  nightdress 
held  between  the  upper  thighs,  or,  prone,  beneath  the  vulva ;  the  heel,  brought 
up  against  the  pudenda ;  vulvar  contacts  with  the  corner  of  a  piece  of  furniture 
or  the  key  in  a  drawer — any  one  of  these  may  constitute  an  individual  process. 
The  vaginal  douche  tube  and  hot  water  excite  very  few  women,  and  the  bicycle 


312  PEUKITUS.       VAGINISMUS.       MASTURBATION. 

saddle  is  to  be  exonerated ;  the  sewing  machine  in  large  shops  has,  however, 
been  accused  of  fostering  the  habit. 

Time. — The  nsual  time  of  indulgence  is  at  the  end  of  menstruation.  The 
day  or  two  immediately  preceding  the  flow  is  the  period  next  most  fertile  in 
temiDtation.  Springtime  brings  attacks  especially  strong.  When  a  pelvic  dis- 
order, such  as  a  cervical  erosion,  occurs  or  gTows  Avorse,  the  torment  is  prone  to 
light  up  again.  An  ordinary  frequency  is  two  or  three  times  in  the  immediate 
neighborhood  of  the  period,  and  once  or  twice  (if  at  all)  between.  This  may 
continue  for  years,  while,  at  times,  months  of  freedom  elapse.  Contrary  to  the 
usual  belief,  the  day  is  as  much  to  be  feared  as  the  night.  Where  a  statement 
is  made  concerning  twelve  or  fifteen  conclusions  in  twenty-four  hours,  it  is 
impossible  not  to  believe  that  in  most  instances  the  climax  is  feeble  or  brief, 
but  it  must  never  be  forgotten  that  women  bear  sexual  excesses  better  than 
men — better,  that  is  to  say,  physically ;  worse,  morally.  With  some  the  solitary 
orgasm  is  said  to  be  no  more  fatiguing  than  the.  normal  relation,  with  others  it 
is  infinitely  more  so. 

Clinical  Findings. — There  are  certain  stages  and  degrees  recognizable  in  the 
development,  and  various  locations,  of  the  hypertrophies  about  the  vulva. 

Stages :  Increase ;  full  development ;  atrophy. 

Degrees :  Moderate ;  average ;  very  great. 

Location :  Labia  minora ;  prepuce ;  fourchette  and  perineum ;  accessory 
nympha? ;  clitoris ;  meatus ;  pelvic  floor  and  levator ;  vagina — eight  in  all,  any 
combination  being  possible.  To  these  may  be  added  varicosities  of  the  broad 
ligament  and  bladder  base,  and  the  mammary  hypertrophies. 

A  typical  case  presents  the  following  changes :  After  pubertj^  the  prepuce  is 
a  tiny  tent  over  a  small  clitoris.  The  lesser  labia  are  smooth  and  of  an  inverted 
V  shape  in  transverse  section,  forming  small,  pink  ridges  closed  in  between  the 
rounded  cushions  of  the  outer  lips.  After  some  months  of  active  traction,  the 
nymphffi  are  larger,  thicker,  darker  along  the  outer  edges,  and,  together  with 
the  prepuce,  exhibit  the  simpler  foldings,  as  well  as  beginning  protrusions. 
Perhaps  some  area  demonstrates  the  pathology  by  characteristic  acute  edema, 
showing  recent  trauma.  Thereafter,  within  two  or  three  years,  the  fullest 
development  may  be  looked  for  in  aggravated  cases,  though  the  maximum 
findings  here  described  as  belonging  to  the  vulvar  habit  are  very  rarely 
grouped  in  a  single  individual.  This  virgin  of  eighteen,  a  well-developed 
brunette  of  excellent  antecedents  and  personal  history,  refined,  reticent,  and 
studious,  is  suffering  from  mental  and  physical  depression,  headache,  dys- 
menorrhea, leucorrhea,  bladder  irritation  and  menorrhagia.  The  breasts 
are  large,  the  nipples  prominent,  the  primary  areola  distinctly  pigmented, 
elevated,  and  bearing  follicles,  with  the  secondary  areola  plainly  visible. 
A  strong  growth  of  pubic  hair  covers  rotund,  coarse-skinned  labia  majora. 
Between  these  outer  labia  protrudes,  in  all  postures,  a  corrugated  roll  of  brown- 
black  skin.  Thickened,  elongated,  curled  on  themselves,  thrown  into  tiny, 
close-set,  irregular  folds  that  cross  at  all  angles  as  in  a  cockscomb,  each  lesser 


eLINICAL    FINDINGS    IN    MASTURBATION.  313 

labium  hangs  in  a  double  fold,  its  anterior  projection  partly  concealing  the 
rear  portion.  Unrolled,  this  little  elephant  ear,  elastic  and  insensitive,  reaches 
one  inch,  or  even  two,  beyond  the  major  a,  and  then  drops  back,  wrinkling  into 
deep  furrows.  The  enlarged  and  prominent  whitish  sebaceous  glands  feel  to  the 
touch  like  a  multitude  of  embedded  sand  grains.  (The  pigment  deposit  is 
present  or  absent  according  to  the  general  coloring.)  The  prepuce,  thickened 
and  lying  in  rounded  folds  or  wrinkling  plaits,  is  continuous  with  these  lesser 
labia.  They  unite  in  a  sweep  behind  the  vulva  so  that  the  fourchette  and  the 
perineal  raphe  are  as  dark  and  corrugated  as  they.  Laterally,  from  them,  two 
bridges  of  the  same  fine-laid  furrowed  folds  run  across  the  shallow  sulcus  that 
lies  between  inner  and  outer  labium  onto  the  labia  majora,  like  an  accessory 
or  intermediate  pair  of  smaller  labia ;  and  this  duplicature  hangs  up  or  puckers 
the  centre  of  each  labium  minus.  The  prepuce  is  partly  adherent,  and  under- 
neath it  smegma  lies  hidden.  The  fully  developed  clitoris  rounds  its  back  and 
projects  its  tip  under  this  thick  cover  nearly  an  inch  in  advance  of  the  face  of 
the  symphysis.  On  each  side  a  couple  of  prominent  veins  twist  along  the  inner 
aspect  of  the  labia  majora.  The  wide  meatus  presents  two  curious  ear-like 
flaps  or  tabs  when  drawn  open.  Into  these  ridges  the  forward  edges  of  the 
hymen  run.  The  openings  of  the  vulvo-vaginal  and  urethral  glands  are  red- 
dened and  gaping.  The  hymen  is  too  small  to  admit  the  finger-tip.  The  deeply 
pigmented  anus  with  its  powerful  sphincter  is  surrounded  with  small  piles,  and 
finally,  the  pelvic  floor  muscles  are  increased  in  vigor  and  thickness  and  in 
susceptibility  to  spasm.     Vaginismus  is  not  uncommon. 

The  last  stage  is  shrinkage,  with  or  without  spotty  pigment.  The  habit 
ceases.  The  vulva  ages.  Its  muscles  relax,  and  the  surfaces  of  the  lesser  labia 
become  smoother  as  the  muscular  and  elastic  fibers  in  them  atrophy,  but  the 
curtain-like  lips  still  show  abnormal  and  characteristic  increase  in  area,  if  not 
in  thickness,  and  still  hang  in  delicate  folds  that  cross  no  longer.  Shrivelling 
is  never  sufficient  to  bring  them  back  to  the  former  narrow  ridge  of  projecting 
skin,  and  although  the  cockscomb  may  smooth  out  its  surface,  some  of  the  hall 
marks  of  the  aggravated  habit  persist  for  life. 

Traction  or  friction  applied  to  the  meatus  or  urethra  result  in  hypertrophies. 
Tiny  ear-like  tabs  or  projections  of  the  lateral  edges  of  the  meatus — on  the  sum- 
mit of  which  elongated  urethral  glands  open — have  been  called  urethral  labia, 
but  they  are  an  enlarged  anterior  section  of  the  hymen  (urethral  hymen). 
Dilatability  or  gaping  of  the  lower  third  of  the  canal  is  sometimes  sufficient 
to  admit  the  finger-tip.  A  varied  assortment  of  articles,  such  as  hairpins,  passed 
into  the  urethra  to  excite  sensation,  have  slipped  into  the  bladder,  and  called  for 
surgical  interference. 

The  vaginal  habit  may  or  may  not  be  a  later  stage  of  vulvar  excitation  in 
any  given  instance.  The  very  gradual  dilatation  of  the  hymen,  extending  over 
a  long  period,  explains  the  remarkable  freedom  from  injury  and  the  astonishing 
elasticity  and  insensitiveness  belonging  to  the  aggravated  cases  of  years  of  pelvic 
floor  massage.    Dr.  R.  L.  Dickinson  has  seen  at  least  fifteen  non-parous  women 


314  PEUEITUS.       VAGINISMUS.       MASTUKBATION. 

in  whom  the  hymen  readily  yielded  to  a  circle  of  six  to  nine  inches,  admitting 
the  hand.  Yet  some  of  these  hymens  spring  hack  to  a  closed  puckered  curtain 
which  the  eye  cannot  distinguish  from  the  virgin  maidenliead.  In  a  later  stage 
of  the  same  habit,  relaxation  has  taken  place  and  the  vulva  sags  open,  though 
the  woman  may  have  had  no  children  at  term.  The  full-term  head  cannot  tear 
these  elastic  pelvic  floors  unless  its  exit  is  precipitate.  The  large  variety  of 
foreigTi  bodies  which  have  been  used  to  supplement  the  digits,  or  have  been 
found  in  the  vagina,  need  not  be  enumerated. 

Effects. — The  physical  results  of  self-abuse,  in  all  but  the  extreme  cases, 
seem  to  be  surprisingly  small.  Endometritis,  vaginal  catarrh,  and  trigonitis 
result  from  long  indulgence.  jSTeurasthenia  is  probably  coincidence  rather  than 
consequence.  Protracted  masturbation,  not  associated  with  sexual  images,  tends 
to  apathy  or  aversion  toward  the  sex-act,  but  the  contrary  is  true  where  there 
is  longing  for  normal  gratification.  In  the  excessive  forms  of  the  vice,  as  with 
relaxed  pelvic  floors,  the  capacity  for  pleasure  in  coitus  is  lost.  If  the  physical 
evils  are  not  many,  the  moral  penalties,  on  the  contrary,  are  disproportionately 
great.  The  undermining  of  self-respect,  the  tortures  and  the  shame  react  on 
the  general  health  surely  and  frequently  and  deeply.  But  there  is  no  diag- 
nostic behavior  or  appearance. 

Diagnosis.- — This  presents  no  difficulty  in  advanced  typical  cases  of  the 
vulvar  habit,  as  described  above,  and  in  general  it  can,  in  my  view,  be  safely 
said  that  no  well-marked  area  of  corrugation  about  the  female  genitals  is  pro- 
duced in  any  way  but  by  pressures.  The  minor  and  the  mental  manifestations 
offer  troublesome  problems,  for  which  space  is  lacking  here.  After  some 
measure  of  the  patient's  good-will  and  confidence  has  been  secured,  and  the 
physician  is  reasonably  certain  of  his  premises,  the  matter  may  be  broached  if 
he  fears  there  is  a  persisting  habit.  There  is  nothing  in  practice  more  diffi- 
cult than  the  approach  to  the  subject — except  perhaps  the  retirement  from  it. 
Good  women,  particularly,  possess  no  lang-uage  and  no  terminology,  either  for 
their  feelings  or  their  anatomy.  Their  words,  meaning  much  or  little,  are  liable 
to  any  kind  of  misconception.  The  sphinx  is  not  more  silent.  Secretiveness 
and  skill  of  fence  are  developed  to  the  highest  degTce.  Denial  springs  in- 
stinctively to  their  lips,  or  professions  of  ignorance  of  what  can  be  meant. 
Therefore,  it  is  best  to  put  through  a  set  speech  steadily.  In  carefully  chosen 
words  the  growth  of  the  habit  in  an  average  case  is  outlined,  and  the  successful 
points  lead  the  patient  to  think  all  her  trouble  is  known.  The  first  alarm  has 
time  to  subside  in  assurance  that  this  is  not  denunciation,  but  help.  Admission 
is  rarelv  to  be  asked  for  in  adults.  The  warning  suffices.  In  voung  girls  the 
threat  of  telling  the  mother  in  case  the  habit  is  continued  forms  a  powerful 
deterrent. 

Preventive  Treatment. — It  rests  with  her  training,  not  whether  a  girl  shall" 
be  tempted,  but  whether  she  shall  be  enslaved  by  the  habit.      Self-control  is 
everything,  with  the  help  of  good  muscle  and  ample  nutrition,  outdoor  tire  and 
cold-water  sprays,  elevating  environment  and  cleanness  of  comrades,  judicious 


TREATMENT    OF    MASTURBATION,  315 

work,  and  wholesome  hardship.  Her  ideals  cannot  be  too  high,  nor  her  con- 
science too  alert,  but  the  stimuli  can  readily  be  too  intense.  Well-timed  and 
reiterated  impact  of  good  influences,  as  in  church  service  and  social  service, 
is  vital,  but  prolonged  religious  emotionalism  has  no  stone  wall  dividing  it  from 
sexual  agitation.  Fervid  preoccupation  with  art,  music,  or  the  literature  of 
feeling  presents  dangers  less  gross,  but  not  less  real  than  contacts  with  loose 
thinking.  From  every  excess  of  intensities  and  unsanities  we  shall  do  well 
to  guard. 

"  Whatever  else  we  may  deem  wise  or  unwise  as  to  the  instruction  of  the 
young  girl  in  the  details  of  sexual  gratification,  there  can  be  no  doubt  about 
their  teachers."  The  physician  is  the  m^oral  sanitarium  directly  responsible. 
It  is  for  him  to  urge  on  the  reserved  woman  what  she  will  call  the  most  difiicult 
task  of  her  life.  Her  telling  is  to  be  matter  of  fact,  yet  reverent ;  neither  vague 
and  sublimated,  nor  specific  and  suggestive ;  not  too  casual,  yet  not  so  freighted 
with  import  and  interest  as  to  arouse  curiosity  and  invite  experiment,  and  with 
just  two  purposes :  namely,  to  so  dispose  the  mind  of  the  child  that  thereafter 
she  shall  bring  to  the  mother  her  questionings,  and  to  anticipate  communications 
from  the  girl's  companions  in  a  matter  wherein  the  right  point  of  view  is  every- 
thing. Thus  by  successive  stages,  as  the  questions  arise,  and  by  illustrations 
drawn  from  plants  and  animals,  the  mother  shows  how  the  holy  mysteries  of 
sex  were  instituted  and  ordained.  In  the  absence  of  researches  amons:  ffirls 
the  proper  age  for  each  stage  cannot  yet  be  defined.  The  Y.  M.  C.  A.  camps 
have  shown  us  that  at  from  eight  to  ten  in  the  tenements  and  from  twelve  to 
fourteen  in  the  better  houses,  the  boy  has  found  out  from  his  comrades  about 
many  sex  matters.  Young  girls  in  school  are  sometimes  surprisingly  informed, 
and  parents  astoundingly  ignorant  of  this  fact.  At  any  rate,  the  reckless  and 
forward,  the  hysterical  and  passionate,  the  brooding  and  introspective  should  be 
studied  and  cautioned.* 

Curative  Treatment. — Confession,  however  fragmentary,  is  a  long  first  step 
toward  recovery.  "  Remorse  for  sexual  sin  is  still  the  religious  teacher's  great 
opportunity."  The  doctor  may  "  show  great  things  and  difficult,"  urge  the 
immediate  action  that  will  break  loose  from  the  particular  vicious  association, 
start  work  to  uplift  others,  and  secure  a  promise  to  report.  These,  with  strong 
mental  suggestion  of  control,  will  go  far.  The  issues  must  be  clear.  The  lure 
of  temptation  lies  largely  in  its  intellectual  vagueness.  To  think  out  the  real 
implications  is  largely  to  loosen  the  habit's  hold.  Whereto  is  all  this  leading? 
The  life  is  readjusted.  House  habits  and  work  habits  are  studied,  and  nerve- 
wrecking  tensions  let  go.  Our  motto  should  be,  "  To  replace  is  to  conquer." 
The  taking  up  of  an  outdoor  hobby,  like  a  nature  study,  can  bring  about  that 
muscular  fatigue  which  is  found  to  be  the  best  single  remedy  for  the  male. 
Swimming,    hydrotherapy,    gymnastic    games,    skating,    tennis,    golf,    wheeling 

*The  Wood- Allen  Publishing  Co.'s  books  (Ann  Arbor,  Michigan)  are  not  condensed  enough, 
but  furnish  an  excellent  guide  for  mothers.  Stanley  Hall's  "Adolescence"  (Appleton)  is  the 
best  scientific  presentation  in  English. 


316  PRUKITUS.       VAGINISMUS.        MASTURBATION. 

and  horseback — all  are  good,  but  bard  to  get  in  cities.  Forced  nutrition  is 
usually  needed,  and  a  general  upbuilding.  Tea,  coffee,  and  alcohol  are  cut  off, 
A  hard  bed  with  minimum  covering  in  a  cool  room ;  immediate  evacuation  of 
the  bladder  when  first  conscious,  and  prompt  rising,  followed  by  the  cold  spray 
or  cold  spinal  douche,  are  desirable.  Bromides  help  over  crises,  whatever  the 
period  of  the  month  or  the  day  temptation  comes,  and  valerianates  spread  this 
quiescence  further,  where  bromides  would  disturb. 

Actual  pelvic  disorder  calls  for  cure,  by  the  briefest  means  available,  in 
order  to  remove  the  local  irritant.  This  is  right  in  all  but  the  neurasthenic 
class.  Here  anatomic  cure  does  not  mean  symptomatic  cure,  except  with  tumors 
and  gross  prolapses.  Care  is  exercised  to  associate  fear  of  pain  with  examina- 
tion. Operation  is  preferred  to  office  treatment  or  home  treatment  on  the  part 
of  the  patient.  Stripping  the  prepuce  is  desirable  whenever  adhesions  are  com- 
plete or  retained  accumulation  considerable.  Circumcision  is  useless^  except 
where  adhesions  with  accumulation  persistently  recur. 

In  conclusion  it  may  be  said  that  whatever  the  divergence  of  opinion  con- 
cerning danger  or  diagnosis,  prevalence  or  effects,  we  can  agree  that  there  is 
on  us  the  troublous  duty  of  moral  prophylaxis,  the  need  of  sane  instruc- 
tion of  the  teachers  of  children,  formulation  and  comprehension  of  what  the 
danger  signals  are,  and  the  mastery  of  means  that  will  strengthen  the  body  and 
energize  the  will.     Inasmuch  as  we  do  it  not — 


CHAPTEE    XIII. 

DISPLACEMENTS  _0F  THE   UTERUS  AND   THEIR  TREATMENT   BY  PACKS 

AND   PESSARIES. 

Normal  position  of  the  uterus,  p.  317.  Abnormal  positions  of  the  uterus,  p.  318.  Diagnosis  and 
symptoms  of  retro-displacements,  p.  322.  Treatment  of  retro-displacements,  p.  323;  packs, 
p.  323;   pessaries,  p.  325;   operative  treatment,  p.  332.     Treatment  of  prolapsus,  p.  333. 

Before  considering  the  question  of  displacements  of  the  uterus  it  is 
important  to  define  briefly  its  normal  position,  because  it  is  the  only  proper 
standard  by  which  to  measure  a  displacement.  If  my  views  as  to  the  normal 
position  of  the  uterus  are  incorrect,  then  I  must,  of  necessity,  estimate  as  mis- 
placements a  great  many  cases  which  are  perfectly  normal. 

The  older  writers  had  the  idea  that  the  uterus  must  lie  in  one  particular 
position  in  the  pelvis,  gently  inclined  forwards  or  slightly  anteflexed,  and  to 
this  norm  they  endeavored  to  accommodate  all  their  patients.  As  a  consequence 
of  this  false  conception,  great  numbers  of  women  were  put  upon  treatment  for 
this  condition  who  needed  none  at  all,  and  the  variety  of  pessaries  devised, 
particularly  for  anterior  displacements  of  the  uterus,  .was  without  end.  With 
a  correct  notion  of  the  posture  or  postures  of  the  uterus,  the  vast  field  of 
anterior  displacement  therapy  disappeared  into  the  gynecological  waste-basket, 
and  with  it  the  host  of  pessaries  over  which  our  immediate  predecessors  spent 
so  much  thought  and  wasted  so  much  ingenuity. 

NORMAL    POSITION    OF    UTERUS. 

The  uterus  normally  lies  in  a  state  of  mobile  equilibrium, 
that  is  to  say,  it  is  poised  or  swung  between  its  broad  ligaments,  ready  to 
respond  to  any  force  however  gentle  exerted  upon  its  anterior  or  posterior  sur- 
faces. It  lies  generally  with  fundus  inclined  forward,  and  cervix  turned  back- 
wards towards  the  lower  part  of  the  sacral  hollow.  As  the  bladder  is  emptied, 
the  fundus  drops  still  further  forward,  and  the  uterus  comes  to  lie  in  a  more 
decided  anteposition,  while  if  the  bladder  becomes  distended,  the  situation  is 
reversed,  and  the  body  is  lifted  on  the  distended  bladder ;  in  cases  of  extreme 
distention  is  even  thrown  over  into  retroposition.  The  general  position  of  the 
normal  uterus  is  fundus  anterior,  cervix  posterior,  and  as  it  swings  in  this 
position,  the  least  increase  of  intra-abdominal  pressure  above  forces  the  viscera 
down  upon  the  posterior  surface  of  the  uterus  and  so  increases  the  ante-displace- 

317 


318  displaceme:xts  of  the  utekits. 

ment.  Xo  anterior  position  of  the  uterus  is  abnormal,  except  that  of  an  ex- 
treme flexion  of  the  bodv  on  the  cervix.  This  is  a  congenital  condition  associated 
with  imperfect  development  of  the  uterus  and  is  not  to  he  remedied  by  palliative 
treatments  through  the  vagina,  or  by  the  use  of  any  kind  of  a  pessary.  It  is  in 
cases  of  this  kind  that  a  dilatation  of  the  cervical  canal  is  often  done,  associated 
with  a  deep  incision  of  the  posterior  wall  of  the  cervix  at  the  angle  of  flexure, 
so  as  to  open  the  cervical  canal  and  secure  free  exit  for  the  menstrual  discharge. 
Plausible  as  such  an  operation  appears  in  the  description,  it  unfortunately  does 
not  often  relieve  the  dysmenorrhea  which  torments  these  patients,  and  although 
successfully  done  to  overcome  sterility,  a  simple  dilatation  of  the  cervix  is,  as 
a  rule,  equally  efiicient. 

ABNORMAL    POSITIONS    OF    UTERUS. 

Categorically  stated,  the  abnormal  positions  of  the  uterus  are  these: 

Anteflexion  (acute). 
Eetroversion. 

Eetroflexion. 

Eight  lateroflexion. 

Left  lateroflexion. 

Ascensus. 

Descensus. 

Prolapsus. 

Torsions. 

jSTumerous  combinations  of  these  malpositions. 

Although  this  list  of  malpositions  seems  a  formidable  one,  there  are  prac- 
tically only  two  or  three  of  them  which  are  of  clinical  sigTiificance.  These  are : 
retroversion  and  retroflexion,  best  considered  together;  descensus; 
and  prolapsus.  Anteflexion,  as  I  have  said,  is  a  congenital  condition, 
causing  in  itself  no  symptoms  and  requiring  no  treatment.  The  other  mal- 
positions are  either  pathological  varieties  or  dependent  upon  some  disease  of 
the  pelvic  organs. 

Ascensus,  or  the  pulling  of  the  uterus  up  into  the  abdominal  cavity,  is  due 
to  an  association  of  the  body  of  the  uterus  with  a  tumor,  such  as  a  fibroid  or  an 
adherent  ovarian  tumor,  gTowing  in  the  direction  of  the  abdominal  cavity;  or 
to  a  slinging  of  the  uterus  to  the  abdominal  wall  by  a  suspension  operation. 
The  displacement  itself  demands  no  particular  attention. 

The  latero-displacements  also  are  produced  by  the  push  or  pull  of  a  tumor ; 
or  by  that  of  a  pelvic  inflammatorv  mass ;  or  by  the  contraction  of  scar  tis- 
sue in  old  inflanmiatory  cases,  which  drags  the  cervix  in  the  direction  of  the 
focus  of  inflammation.  These  conditions  demand  notice  only  as  clinical  feat- 
ures of  value  in  making  a  diagnosis  in  connection  with  pelvic  inflammatory 
trouble. 


ABNORMAL    POSITIONS    OF    THE    UTEEUS. 


319 


Torsions. — A  slight  degree  of  rotation  low  down  on  the  right  side  exists 
commonly  and  may  almost  be  considered  normal.  Any  inflammatory  disease 
causing  an  unsymmetrical  drag  or  pull  may  exaggerate  this.  Large  myomatous 
tumors  and  tumors  of  the  ovary  may  cause  such  twisting  as  to  completely  shut 
off  the  circulation  and  cause  gangrene.  Such  conditions  are  usually  considered 
under  tumors  of  the  uterus  or  ovaries. 

Retropositions  are  by  far  the  most  important.  It  is  in  retroversion  and 
retroflexion,  especially  when  associated  with  descensus,  that  the  patient's 
general  health  is  liable  to  suffer,  and  she  experiences  local  discomforts ;  it  is  in 
these  cases,  therefore,  that  an  appropriate  therapy  is  always  likely  to  afford 
entire  relief. 

Between  anteflexion  and  retroflexion  with  descensus,  the  uterus  occupies  a 
number  of  positions,  as  shown  in  Figure  81.     If  a  case  is  watched  from  the 


Fig.  81. — Different  Degrees  of  Uterine  Displacement,  from  a  Normal  Slight  Anteflexion  to 
A  Decided  Retroflexion  with  Descensus. 


first,  these  steps  on  the  backward  and  downward  progress  may  be  recognized, 
even  to  its  final  appearance  at  the  outlet  and  its  escape  as  a  complete  prolapsus. 
Frequency  of  Retroflexions. — The  relative  frequency  of  retroflexion, 
as  contrasted  with  other  gynecological  ailments,  is  found  in  the  following  state- 
ment taken  from  my  records  at  the  Johns  Hopkins  Hospital :  Out  of  the  thirteen 
thousand  and  six  hundred  gynecological  cases,  there  were  eleven  hundred  and 


320 


DISPLACEMENTS    OF    THE    UTEETTS. 


eightv-six  of  retroflexion,  and  of  this  number  four  hundred  and  fifteen  were 
uncomplicated  retroflexions,  three  hundred  and  sixteen  being  associated  with 
pelvic  adhesions,  a  broken-down  vaginal  outlet  (commonlv  called  laceration  of 
the  perineum),  appendicitis,  etc.. 

Out  of  one  thousand  operations  of  all  kinds,  extending  from  August  27, 
1904,  to  iSTovember  9,  1905,  there  were  ninety-five  cases  of  retroflexion;  of  this 
number  sixty-nine  were  married  women  and  twenty-six  were  single.  In  ten 
per  cent  of  the  ninety-five  cases  an  operation  was  done  upon  the  vaginal  outlet. 

Varieties  of  Retroflexion  and  Retroversion  of  the  Uterus. 
— These  forms  of  displacements  differ   according  to  whether  they   are  found 

in  nulliparc'e  or  in  parous 
women.  In  the  nuUiparous 
woman  and  in  the  virgin,  a 
tilting  back  of  the  uterus  is 
not  infrequently  found,  in 
which  the  uterus  lies,  as  it 
were,  reclining  in  the  sacral 
hollow,  as  one  rests  at  ease 
in  a  rocking  chair.  If  there 
are  no  symptoms  of  pelvic 
pain,  irregular  catamenia, 
and  dysmenorrhea,  such  dis- 
placements do  no  harm  what- 
ever, and  ought  not  to  be 
treated.  Where  the  vagina 
is  preternaturally  short  a 
Fig.  82. — A  Retroflexion  which  is  NATniAL  axd  caxxot     retroflexion    mUSt    be    COnsicl- 

BE    COHEECTED    OX   AcCOTTXT     OF    THE    AbXORMALLY   ShORT  -,  ■,  -, 

Yagixa.     The  anterior  fornix,  although  it  can  be  pushed     erecl    aS    tilC    UOrUiai    pOSltlOn 

of^SUTe?^'"''"'^'''''"*'^''"^^'''^^^*^^'''^^^''*^"'''*    foi'  ^^le  Uterus  (see  Fig.  82). 

There  is  no  doubt  at  all 
that  thousands  of  young  women  are  under  treatment  for  retrodisplacements, 
impressed  by  their  physicians  that  it  is  a  serious  malady,  who  would  be  far 
better  off  if  they  were  let  entirely  alone,  or  if  the  time  and  money  expended 
were  directed  to  the  simple  endeavor  to  build  up  their  health.  At  the  same 
time  there  are  occasional  cases  in  young  women,  in  which  there  is  a  marked 
downward  displacement,  with  the  fundus  of  the  uterus  tilted  backward,  and 
often  associated  with  a  misplaced  ovary,  where  there  is  a  distinct  dragging 
pain  and  a  marked  dysmenorrhea.  In  such  cases  where  the  symptoms 
are  distinctly  local  and  clearly  referable  to  displacement,  gTeat  relief  generally 
follows  replacement  of  the  uterus.  It  is  the  cases  of  neurasthenia,  with 
more  or  less  general  aches  and  pains,  and  suffering  which  seems  more  particu- 
larly ovarian  in  character,  that  are  rarely  relieved  by  mechanical  methods. 

Retroflexion  in  a  woman  who  has  borne  one  or  more  chil- 
dren is  associated  with  a  relaxation  of  the  broad  ligaments,  and  with  a  rupture 


PKOLAPSUS    OF    THE    UTEEUS, 


321 


at  the  vaginal  outlet,  involving  the  levator  ani  fibres,  and  leaving  the  outlet 
gaping,  with  more  or  less  eversion  of  the  anterior  and  posterior  vaginal  walls. 
The  cervix  in  such  cases  is  at  a  much  lower  point  in  the  vagina  than  is  normal, 
in  fact  that  conditions  seem  almost  reversed.  The  cervix  lies  forward,  one  or 
two  finger  breadths  from  the  symphysis,  while  the  fundus  lies  backward,  low 
down  in  the  sacral  hollow,  where  the  cervix  formerly  lay.  The  examination  in 
such  a  case  is  not  completed  until  the  patient  is  examined  while  standing,  with 
one  of  her  feet  resting  on  a  low  stool.  While  in  this  position,  on  making 
the  least  strain,  the  vaginal  Avails  are  felt  to  roll  out,  and  the  cervix  is  found  to 
descend  lower  in  the  vagina. 

Prolapsus  of  the  uterus  is  simply  an  advanced  stage  of  this  retrodisplace- 
ment  just  described,  associated  with  descensus,  which  is  the  first  step 
towards  the  formation  of  a  complete  prolapse.  A  complete  prolapse,  or 
escape  of  the  entire  uterus  from  the  pelvic  cavity,  is  rarely  brought  about 
within  a  short  period  of  time;  as  a  rule,  the  descensus  increases  week  by 
week  until  the  cervix  appears  at  the  vaginal  outlet,  and  next  escapes  from  the 
outlet,  until  finally  the  entire  uterus,  or,  it  may  be,  a  long  drawn  out  supra- 


FiG.  83. — A  Case  of  Complete  Prolapse  of  the  Uterus  with  both  Vaginal  Walls. 
with  the  cervix,  hangs  hke  a  bag  between  the  thighs. 


The  vagina, 


vaginal  cervix,  like  a  stem  of  -macaroni,  communicating  with  the  body  above, 
hangs  between  the  thighs  (see  Fig.  83),  at  the  apex  or  on  the  anterior  surface  of 
a  sac  made  up  of  vaginal  walls,  containing  a  diverticulum  from  the  bladder  in 
front,  and  it  may  be  some  projection  of  the  rectum  or  the  small  intestines  behind. 
The  pain  present  in  these  cases  is  most  aggravated  when  the  prolapsus  is 
in  the  process  of  formation,  while  the  dragging  is  still  going  on,  and  the  tis- 
33 


322  DISPLACEMENTS    OF    THE    UTERUS. 

sues  are  yielding.  When  the  prolapse  is  completed,  altliougli  the  patient  may 
be  greatly  incommoded  by  the  mass,  the  sacropnbic  hernia,  which  hangs 
between  her  thighs,  the  suffering  is  not  so  great,  as  there  is  no  longer  any 
stretching  going  on. 

Prolapsus  is  usually  found  in  women  well  over  forty,  no  longer  in  the 
child-bearing  period,  so  that  for  this  as  well  as  for  mechanical  reasons,  preg- 
nancy is  extremely  rare.  The  chief  dangers  in  this  condition  are  associated 
with  the  difficulty  in  emptying  the  bladder.  Cystitis  may  occur,  stones  may 
be  formed  in  the  sacculus  lying  in  the  hernia,  and  an  ascending  infection  may 
cause  death.    As  a  rule,  however,  there  is  but  little  danger  to  life. 

Symptoms  and  Diagnosis  of  Retrodisplacements. — A  retroflexion  is  objec- 
tionable because  of  the  disabilities  it  induces.  The  patient  who  was  once 
active  and  energetic  now  feels  more  or  less  tired  all  the  time,  has  a  dragging 
sensation  generally  referred  to  the  brim  of  the  pelvis  posteriorly,  is  apt  to 
suffer  from  constipation  and  prolonged  menstruation,  and  is  often 
seriously  incommoded  by  frequent  urination.  If  pregnancy  occurs,  an 
abortion  is  apt  to  take  place;  although  in  favorable  cases,  the  uterus  rights 
itself,  and  after  the  third  or  fourth  month  there  is  no  further  difficulty,  but 
rather  a  relief.  If  the  retroflexed  pregnant  uterus  becomes  incarcerated  and 
unable  to  escape  from  the  promontory  up  into  the  abdomen,  as  a  rule,  an 
abortion  takes  place.  This  is  the  simplest  and  safest  solution.  Sometimes 
the  pressure  is  so  great  as  to  occlude  the  urethra  and  cause  an  exfoliation  of 
the  vesical  mucosa.  A  simple  manual  replacement,  with  the  patient  in  the 
knee-breast  position  under  anesthesia,  in  which  the  cervix  is  pulled  doT\Ti 
towards  the  outlet,  while  the  fundus  is  pushed  up  with  two  fingers  introduced 
into  the  emptied  rectum,  will  at  once  relieve  all  discomforts  and  place  the 
uterus  in  a  position  to  carry  its  burden  to  term. 

The  diagnosis  of  retrodisplacement  is  made  by  feeling  the  cervix  lower 
dovTi  in  the  vagina  than  its  normal  position,  instead  of  lying  well  up  at  the 
vault,  while  the  rounded  fundus  is  easily  felt  through  the  posterior  vaginal 
vault  (see  Fig.  81,  p.  319).  The  rounded  mass  at  the  posterior  vaginal  vault 
must  be  distinguished  from  an  ovarian  tumor  or  a  fibroid  tumor  of  the  pos- 
terior surface  of  the  uterus.  This  is  done  in  the  first  place  by  grasping  the 
cervix  with  the  tenaculum  forceps  and  drawing  it  down,  while  the  finger  dis- 
tinctly recognizes  the  continuity  between  the  cervix  and  the  fundus  in  the  angle 
posteriorly.  Then  upon  making  a  bimanual  examination,  with  one  hand  pal- 
pating through  the  abdominal  walls,  the  absence  of  any  fundus  anterior  to  the 
cervix  is  noted,  while  at  the  same  time  the  fundus  felt  below  can  be  pushed  up 
so  as  to  come  within  the  reach  of  the  abdominal  fingers.  If  there  is  any  doubt 
about  the  condition,  a  little  anesthesia  will  enable  the  operator  to  make  a  still 
more  searching  examination  bimanually  through  the  rectum  and  the  abdominal 
wall,  bringing  the  finger  into  the  closest  contact  with  the  posterior  surface  of 
the  uterus,  and  enabling  him  to  outline  the  ovaries  at  either  side. 

In  examining  a  young  woman  with  an  intact  hymen,  it  is  always  best  to 


TREATMENT    OF    EETRODISPEACEMENTS. 


323 


spare  her  feelings  and  suggest  an  anesthetic  at  once,  to  clear  up  the  situation. 
I  find  as  a  rule  that  nitrous  oxide  gas  is  sufficient  for  this  purpose;  if  it 
does  not  produce  enough  relaxation,  a  little  ether  may  be  given.  Where  an 
anesthetic  is  objectionable,  a  ten  per  cent  solution  of  coca  in  may  be  inserted 
by  the  nurse,  upon  a  pledget  of  cotton  attached  to  a  thread  placed  just  behind 
the  hymen;  this  measure  obliterates  the  sensitiveness,  after  which  the  exam- 
ination can  be  made  with  far  less  distress  and  resistance  on  the  part  of  the 
patient.  The  examiner  ought  always  to  avoid  any  injury  to  the  hymen.  This 
can  be  done  by  conducting  the  entire  examination  through  the  rectum.  It  is 
my  rule  in  such  cases  to  suggest  to  the  patient,  if  she  has  been  complaining 
of  dysmenorrhea,  that  any  simple  operation,  such  as  a  thorough  dilatation, 
should  be  done  at  once,  so  as  not  to  subject  her  to  the  discomfort  of  two  acts 
of  anesthesia. 

Treatment   of   Retrodisplacements. — The   treatment   of   a   retrodisplacement 
may  be  either    palliative    or    radical.      Among  the  palliative  treatments 


Fig.  84. — Showing  Manner  of  Applying  a  Gauze  Pack  to  the  Vault  of  the  Vagina  by  Means  of 
A  Packer,  for  the  Purpose  of  Holding  the  Uterus  up  and  in  Place. 

must  be  reckoned  the  application  of  packs  to  the  vagina,  with  a  view  of  hold- 
ing up  the  uterus,  and  the  use  of  pessaries  for  the  same  purpose.  Radical 
treatments  are  operative  in  character.  A  vaginal  pack,  or  tampon,  is  made  of 
large  pledgets  of  absorbent  cotton  or  wool,  or  of  a  long  strip  of  gauze  (see  Fig. 
84)  saturated  with  some  drug,  and  introduced  into  the  vagina,  .where  it  forms 


324  DISPLACEMEXTS    OF    THE    UTERUS. 

a  supporting  column,  holding  nj)  the  nterns.  The  medicament  most  commonly 
used  is  a  solution  of  boric  acid  in  glycerin,  called  boroglycerid.  A 
teaspoonful  C)f  this  is  laid  in  a  piece  of  absorbent  cotton,  shaped  like  a  little 
saucer,  attached  to  a  thread.  This  is  then  placed  at  the  vaginal  vault  under  the 
cervix  with  a  thread  hanging  outside.  One  or  perhaps  two  or  more  pledgets  of 
cotton  are  similarly  introduced,  using  an  instrument  called  a  packer,  to  carry 
the  cotton  up  into  place.  Underneath  the  pledgets  of  cotton  it  is  well  to  place  a 
tampon  of  wool,  which  does  not  collapse  like  the  cotton,  and  gives  an  elastic 
support  to  the  whole.  Such  a  tampon  should  be  left  in  place  from  twelve  to 
twenty-four  hours,  after  which  the  patient  removes  it  and  takes  a  douche,  using 
permanganate  of  potash,  two  to  three  per  cent,  in  warm  water  for  the 
jDurpose;  or  a  teaspoonful  of  Labarraque's  solution,  the  formula  for 
which  is  as  follows: 

^   Liq.  soda;  chlorinatse oj 

Aqu£e Oj 

■  M.     S.  Use  as  a  vaginal  douche. 

Such  packs  may  be  renewed  from  week  to  week,  the  douching  being  con- 
tinued in  the  intervals.  A  pack  is  not  to  be  left  in  for  several  days,  as  it  is 
liable  to  become  sour  and  to  set  up  irritation.  A  good  plan  of  putting  in  a  pack 
is  to  place  the  patient  in  the  knee-breast  position  and  lift  up  the  perineum, 
when  the  whole  vagina  balloons  out,  and  it  is  much  easier  to  place  a  suppository 
or  a  supporting  pack  in  position.  The  cervix  should  be  drawn  down  with  a 
tenaculum,  so  as  to  dislodge  a  non-adherent  fundus  or  to  gain  as  much  room  as 
possible,  should  it  be  adherent.  The  action  of  the  pack  is  for  the  boro- 
glycerid to  provoke  a  free  watery  discharge  and  thereby  deplete  the  sur- 
rounding tissues,  while  the  cotton  and  wool  form  an  elastic  supporting  colimin 
within  the  vagina  on  which  the  uterus  rests,  preventing  displacement  down- 
wards when  the  patient  is  on  her  feet  and  propping  the  distended  walls  of  the 
pelvic  blood  vessels,  thus  giving  the  patient  a  sense  of  relief.  I  sometimes  see 
patients  who  have  become  accustomed  to  the  use  of  packs  where  no  displace- 
ment or  anatomical  abnormality  of  any  kind  whatever  can  be  detected.  Such 
patients,  who  have  worn  packs  a  long  time,  experience  a  sense  of  discomfort 
without  them,  and  unless  a  strong  effort  is  made  to  wean  them  from  the  prac- 
tice, they  are  likely  to  remain  tied  to  the  doctor's  office  from  year  to  year. 
Cases  of  this  sort,  where  there  is  really  no  trouble  demanding  the  pack,  are  a 
disgTace  to  the  gynecological  profession. 

Pessaries  in  Retrodisplacement  and  Descensus. — Pessaries  are 
valuable  instruments  in  giving  relief  in  cases  of  ret rodispla cement,  or 
descensus,  or  both.  As  a  rule,  their  use  is  only  temporary,  for  a  few  weeks 
or  months,  when  an  appropriate  0]>eration  should  be  done  so  as  to  free  the 
patient  from  the  necessity  of  local  treatment.  Sometimes,  however,  as  in  pro- 
lapsus in  an  older  woman  who  has  a  serious  organic  disease,  such  as  a  heart 
lesion,  and  an  operation  is  contra-indicated,  a  pessary  is  used  permanently  to 


KULES    FOE    THE    USE    OF    PESSAKIES.  325 

keep  up  the  uterus  and  vaginal  walls.     The  various  forms  of  pessary  are  shown 
in  Figure  85. 

Pessaries    ought  always  to  he  made  of    hard    ruhher.      Soft  rubher 
should  he  discarded,  as  it  becomes  foul  and  provokes  vaginitis.     The  hard-rub- 


FiG.  85. — The  Five  Most  Useful  Kinds  of  Hard-rubber  Pessaries.  Their  Size  is  Slightly  Re- 
duced AS  SHOWN  BT  THE  CENTIMETRE  MEASURE  Below.  (1)  Smith  pessary  with  strong  Upper 
curve  of  the  posterior  bar  and  pointed  nose.  (2)  Hodge  pessary  with  broad  anterior  bar;  the  curved 
form  of  the  pessary,  seen  from  the  side,  is  shown  on  the  right.  (.3)  Comn:ion  hard-rubber  ring 
pessarjr,  the  most  generally  useful  of  all.  (4)  Gehrung  pessary,  the  most  valuable  form  in  cases  of 
cystocele,  and  in  prolapse  where  the  vaginal  outlet  is  still  good ;  the  outline  of  this  pessary  is  shown 
on  the  right.  (5)  Reinforced  Munde-Thomas-Smith  pessary.  Thomas  added  the  thickening  of  the 
posterior  bar  to  the  Smith  pessary  (1) ;  while  Munde  changed  the  pointed  nose  of  the  anterior  bar 
into  a  broader  one,  more  like  the  Hodge  form.     All  these  pessaries  are  made  in  several  sizes. 

ber  pessaries  may  be  left  in  place  for  periods  varying  for  from  several  months 
to  a  year.  The  operator  should  be  sure  when  the  pessary  is  introduced  that  it 
is  perfectly  clean.  A  pessary  should  never  be  taken  from  one  patient  and,  after 
simple  washing,  introduced  into  another.  The  ring  pessary  alone  of  all  the 
different  kinds  can  be  disinfected  by  boiling  in  water.  Other  pessaries,  which 
are  liable  to  lose  their  form  by  boiling,  should  be  washed  with  soap  and  hot 
water  and  then  immersed  in  a  solution  of  bichloride  of  mercury  for 
several  days.  The  use  of  the  pessary  is  simply  to  spread  out  the  vaginal  walls. 
When  the  uterus  is  freely  movable,  it  may  be  put  in  a  normal  position  before 


326 


DISPLACEMENTS    OF    THE    UTERUS. 


a  pessary  is  placed.  A  measurement  should  be  made  of  the  length  of  the  vagina, 
by  means  of  the  finger  or  a  sound,  from  the  upper  limit  of  the  posterior  cul- 
de-sac  down  to  the  posterior  surface  of  the 
symphysis  at  a  point  corresponding  to  the  junc- 
tion of  the  lower  and  middle  thirds  of  the 
urethra,  in  order  to  determine  the  length  of 
the  pessary  to  be  used. 


Fig.  86. — Showing  Method  of  Bimantjal  Reposition  of  a  Reteoflexed  Uterus.  Note  index 
finger  of  left  hand  pushing  the  cervix  forward,  while  the  right  hand  presses  upon  the  posterior  surface 
of  the  fundus  uteri. 

Manual  Reduction. — Let  me  say  here  that  manual  reduction  of  the 
uterus,  while  it  seems  an  ideal  procedure  as  it  appears  on  a  diagram,  lacks  two 
important  elements  of  the  ideal  in  actual  practice.  In  the  first  place  it  is  not 
always  easy  to  accomplish  and  may  hurt  the  patient  a  good  deal ;  in  the  second 
place,  a  uterus  so  replaced,  as  a  rule,  refuses  to  stay  where  it  has  been  put. 
For  this  reason,  I  do  not  pause  to  lay  great  stress  on  this  phase  of  the  treatment 
of  retrodisplacements.  The  replacement  is  effected  by  getting  hold  of  the  back 
of  the  fundus  with  the  hand  on  the  abdomen  (see  Fig.  86),  at  the  same  time 
pushing  the  cervix  back  with  the  finger  of  the  other  hand,  in  this  way  assist- 
ing the  organ  to  reach  its  normal  fundus-ante  position.  After  replacement  it 
is  well  to  exaggerate  the  anterior  position  decidedly  before  putting  in  the  tampon 
(see  Fig.  87). 

It  sometimes  happens  that  the  simple  introduction  of  a  pessary  sets  a  retro' 
position  of  the  uterus  into  anteposition.  Before  introducing  the  pessary  the 
vagina  should  be  clean  and  the  bowel  free  of  fecal  matter.  The  well-lubricated 
pessary  is  then  placed  inside  of  the  vagina,  encircling  the  cervix  as  if  it  is  a 
ring,  and  this  may  be  done  without  attempting  to  raise  the  fundus ;  the  pessary 
itself  will  often  serve  to  correct  the  retroposition  of  tlie  uterus,  if  its  presence  is 
sufficient  to  maintain  the  uterus  in  a  correct  position.     The    essential    con- 


RULES    FOR    THE    "USE    OF    PESSARIES. 


327 


ditions  for  the  use  of  a  pessary  are  the  absence  of  a  lateral 
inflammatory  disease,  which  would  be  aggravated  by  the  hard  sides  of 
the  pessary,  and  a  vaginal  outlet  sufficiently  closed  or  snug 
enough  to  keep  the  pessary  within  the  vagina.  If  the  vaginal  out- 
let is  much  broken  down,  any  pessary,  however  well  placed,  will  roll  out  as 
soon  as  the  patient  is  on  her  feet,  or  with  the  first  act  of  straining. 

There  is  one  pessary,  the  Gehrung,  which  will  correct  an  eversion  of  the 
anterior  vaginal  w^all,  called  a  cystocele.  The  pessary  is  held  in  the  fingers, 
as  shown  in  the  diagram  (see  Fig.  85,  'No.  4),  and  inserted  by  hooking  it  down 
over  the  perineum,  and  then  rotating  it  gently  till  the  entire  pessary  is  brought 
within  the  vagina.  It  is  then  turned  with  the  index  finger,  pressing  on  one  or 
the  other  of  its  bars  until  the  cervix  comes  to  lie  in  the  position  shown  in  the 
diagram.  Other  pessaries  commonly  used  are  the  simple  ring  (Fig.  85,  ISTo.  3) 
in  sizes  from  four  to  ten  centimetres  in  diameter;  and  the  rubber  ring,  which 
should  be  about  ten  millimetres  in  thickness ;  it  is  a  serious  mistake  to  use 
rings  made  of  narrow  rubber  less  than  six  millimetres  in  thickness,  as  these 


Fig.  87. — Shows  an  Exaggeration  of  the  Normal,  Anteflexion  of  the  Uterus,  Produced  by 

Bimanual  Manipulation. 


are  more  liable  to  cut  through  the  vaginal  walls.  Whenever  there  is  some 
tendency  to  prolapsus,  it  is  better  to  use  rings  with  thicker  margins,  and  in 
prolapsus,  a  disc  of  rubber  is  often  valuable,  with  simply  a  little  hole  (one  to 
two  centimetres  in  diameter)  in  the  middle.  In  such  cases  a  shell  pessary  is 
often  useful.     I  believe,  as  a  rule,  hard-rubber  rings  will  serve  all  the  purpose 


Fig.  88. — Showing  Manner  of  Introdttcing  a  Ring  Pessary,  by  Drawing  Back  the  Posterior 
Vaginal,  Wall,  and  Pressing  Back^svard  with  the  Pessary  as  it  is  Introduced  in  a  Slightly 
Oblique  Direction.  It  is  important  to  avoid  pressing  upon  the  pubic  bone  or  the  more  sensitive 
structures  near  the  symphysis. 


Fig.  89. — Showing  Manner  of  Introducing  a  Smith  Pessary.  The  index  finger  of  the  left  hand  pulls 
back  the  vaginal  waU,  while  the  right  hand  introduces  the  pessary  without  bruising  the  structures 
lying  anteriorly. 

328 


INTRODUCTION    OF    PESSARIES. 


329 


and  fulfil  nearly  all  indications  better  than  the  so-called  lever  pessaries,  known 
as  the  Hodge,  Albert  Smith,  Smith-Thomas,  Smith-Thomas-Mnnde  (Fig.  85, 
!Ro.  5).  When  a  lever  pessary  is  used  in  retroflexion,  the  broad  posterior  bar 
of  the  Thomas  pessary  is  more  satisfactory  than  the  old-fashioned  Smith,  while 
the  same  pessary  with  a  square  nose  in  front  is  more  satisfactory  than  the 
pointed  nose  of  the  Albert  Smith  pessary.  The  pessary  ought  never  to  stretch 
the  walls  of  the  vagina  so  as  to  produce  an  ischemia.  It  is  a  temptation,  it 
appears,  to  many  physicians  to  insert  a  large  pessary,  of  the  style  which  I  have 
long  called  a  Horse  Pessary;  this  stretches  the  vaginal  walls  out  tremendously 
in  every  direction,  producing  a  result  which  would  be  very  satisfactory  if  the 
instrument  did  not  lie  in  contact  with 
living  tissues  liable  to  ulcerate.  A 
pessary  should  fit  snugly,  but  rather 
loosely,  although  not  so  loosely  as  to 
be  unable  to  keep  its  position.  There 
should  be  room  on  all  sides  to  insert 
easily  between  the  pessary 
If  it  is  uncer- 
tain what  kind  of  a  pessary  to  use,  it 
is  best  to  start  out  by  trying  a  ring. 
Then  if  this  does  not  do  well,  to  try, 
say  the  Smith-Thomas-Munde.  The 
ring  pessary  is  inserted  in  the  man- 
ner shown  in  Figure  88,  pushing  pos- 


a   finger 

and  the  vaginal  wall. 


teriorly    against    the    perineum. 


and 


avoiding  any  violent  impact  on  the 
urethra  or  the  anterior  vulvar  tissues. 
The  Smith  or  Munde  pessaries  are 
held  and  inserted  in  the  manner 
shown  in  the  diagram  (see  Fig.  89). 
After  thus  slipping  the  pessary  into 
the  vagina,  it  is  put  in  position  by  the 
index  finger  pressing  the  posterior  bar 
back  behind  the  cervix  (see  Fig.  90). 


Fig.  90. — Showing  Manner  of  Carrying  Smith 
Pessary  into  Place.  The  pessary,  having  been 
introduced  into  the  vagina,  is  caught  by  the  in- 
dex finger,  which  rests  upon  its  posterior  bar,  and 
carried  well  behind  the  cervix,  when  the  pessary  is 
in  position. 


The  whole  pessary  should  then  lie  well 


within  the  vagina  and  behind  the  symphysis,  and  no  part  should  be  visible  at 
the  vaginal  outlet.     Figure  91  shows  ring  pessary  in  position. 

The  thick  ring  pessaries,  the  disc  pessaries,  the  shell  pes- 
saries, and  the  bayonet  handle  pessaries  (Menge)  should  be  reserved 
for  prolapsus  cases.  In  these  cases,  the  pessary  must  be  larger,  as  a  rule,  than 
for  retroflexion,  so  as  to  take  up  more  space  in  the  overstretched  vagina,  and  at 
the  same  time  too  large  to  escape  through  the  vaginal  outlet  when  once  intro- 
duced. The  simpler  the  form  of  pessary  which  does  the  work,  the  better  for  the 
patient.  Sometiuies  a  pessary  seems  to  fulfil  the  indication  in  an  ideal  man- 
ner, so  long  as  the  patient  is  on  her  back,  but  as  soon  as  she  gets  on  her  feet, 


330 


DISPLACEMENTS    OP    THE    UTEEUS. 


the  part  lying  behind  the  symphysis  slips  down,  appears  at  the  vulva,  and  so 
escapes.  The  physician  here  realizes  that,  if  in  some  way  he  could  prevent  the 
pessary  falling  forward  in  this  manner,  he  would  be  able  to  keep  it  inside, 
and  so  give  entire  relief.     This  indication  was  met  by  our  predecessors  by  the 


Fig.  91. — Sho'wixg  a  Rdjc  Pessary  en^  Place,  axd  its  Relatioxs  to  the  Cervix  an"d  the  Vault  of 

THE  Vagena. 


Zwank  pessary,  an  instrument  which  could  be  introduced  closed  and  then 
opened  out  by  means  of  a  screw  arrangement  in  the  handle.  These  pessaries, 
however,  did  incalculable  harm  in  cutting  through  into  the  tissues,  and  have, 
for  this  reason,  fallen  into  a  well-deserved  disrepute.  This  indication  is  well 
met  by  the  Menge  pessary,  with  a  rounded  stem,  which  is  inserted  into  the 
pessary  and  fixed  with  a  bayonet  lock  after  the  pessary  has  been  introduced 
(sec  Fig,  92).  Pessaries  cause  abrasion  or  ulceration  of  the  vagina  because 
they  are  too  large  and  exert  undue  pressure  in  one  place,  or  because  the  polished 
surface  of  the  hard  rubber  becomes  incrusted  with  lime  salts  and  thus  roughened. 
To  gaiard  against  this  roughening  and  to  make  sure  that  the  pessary  fits  well,  it 
should  be  removed  and  inspected  after  each  menstrual  period  for  several  months, 
and  thereafter  at  intervals  of  two  or  three  months  during  the  time  it  is  worn. 


IWTRODTJCTIOiq"    OF    PESSAKIES. 


331 


In  fitting  a  pessary  it  is  often  necessary  to  bend  it.  To  do  this  without 
destroying  the  polish  it  must  be  thoroughly  greased  and  held  just  above  the 
flame  of  an  alcohol  lamp,  taking  care  not  to  let  the  grease  catch  fire,  for  if  it 
does  the  rubber  will  burn,  leaving  a  rough  spot. 

Patients  who  wear  pessaries  find  it  necessary,  as  a  rule,  to  use  douches; 
a  good  douche  is  made  of  sodium  bicarbonate  and  borax,  a  teaspoonful 
of  each  to  the  pint  of  warm  water,  which  can  be  taken  once  a  day  injected 
with  a  Davidson's  syringe,  using  the  long  hard-rubber  nozzle  introduced  to 
its  fullest  extent  into  the  vagina.     If  a  drop  of    menthol    is  added  to  this 


Fig.  92. — ^A  Form  of  Pessary  (Menge)  Useful  in  Some  Cases  of  Prolapse  of  the  Uterus.     The 
stem  prevents  the  pessary  from  rotating  and  thus  from  presenting  at  the  vaginal  outlet  and  escaping. 

and  thoroughly  mixed  with  the  powder  before  dissolving,  the  douche  is  more 
refreshing. 

'^  Menthol gtt.  j 

Sod.  bi-carb 3j 

Sod.  bi-borat 3j 

S.     Dissolve  in  a  pint  of  hot  water  and  use  as  a  douche. 


332 


DISPLACEMETiTTS    OF    THE    UTERTTS. 


Vaginal  suppositories  of  borogljcerid  and  gelatin  plain  or  combined 
with  Hydrastis,  ichthjol,  tannin,  or  alnm,  are  often  useful  in  place 
of  the  douche. 

Operative  Treatment. — The  radical  or  operative  treatment  for  retro- 
displacements  consists  in  the  use  of  natural  or  artificial  supports  to  hold  the 
uterus  in  an  anteposition  and  keep  the  fundus  forward  in  advance  of  the 
cervix.  The  simplest  form  of  operation  is  that  used  in  nulliparous  women 
where  one  of  several  supra-pubic  operations  may  be  employed.  The  Alexander 
operation  acting  on  the  round  ligaments  by  shortening  them  in  the  inguinal 
canal  has  long  been  in  vogue,  but  it  is  at  present  being  generally  abandoned. 


Fig.  93. — Shows  the  Different  Steps  in  an  Operation  for  Prolapse  of  the  Uterus.  (1)  Rep- 
resents the  amputation  of  the  cer^dx  by  removal  of  the  area  indicated  by  shading.  (2)  Represents 
the  resection  of  the  anterior  vaginal  wall  for  correction  of  the  cystocele.  (3)  Shows  the  operation 
for  building  up  the  vaginal  outlet  and  thus  narrowing  the  opening.  (4)  Is  the  suspensorj.-  ligament 
attaching  the  fundus  to  the  abdominal  wall.  (5)  Represents  the  alternate  operation  to  this,  namely, 
the  shortening  of  the  round  ligament  by  Gilliam's  operation. 


The  advisability  of  such  an  operation  belongs  to  a  specialist,  but  the  general 
practitioner  must  judge  what  cases  it  is  desirable  to  send  him  for  advice. 

For  the  information  of  the  physician,  I  have  indicated  two  of  the  forms  of 
operation  used  for  the  correction  of  an  extreme  prolapse.     In  one,  the  simpler, 


TEEATMEISTT    OF    PROLAPSUS. 


333 


the  cervix,  wliicli,  as  a  rule,  is  elongate,  is  amputated  (see  Fig.  93,  1)  then 
the  anterior  vaginal  wall  is  resected  (Fig.  93,  2)  ;  and,  finally,  the  vaginal 
outlet  is  built  up  so  as  to  give  a  strong  support  to  the  outlet  (Fig.  93,  3). 
An  abdominal  operation  may  be  added  to  hold  the  vagina  forward,  either  by 
direct  action  of  the  fundus,  or  by  drawing  the  round  ligaments  through  the 


Fig.  94. — An  Operation  for  the  Cure  of  Prolapsus  in  Women  Who  have  Passed  the  Child-bear- 
ing Period  and  tvhere  there  is  a  Marked  Cystocele.  The  uterus  is  intereallated,  or  fixed 
between  the  bladder  and  the  anterior  vaginal  wall.  The  shaded  area  in  the  perineum  represents  the 
customary  closure  of  the  relaxed  opening. 


abdominal  wall  (Gilliam's  operation).  In  the  other  forms  of  operation,  which 
effectively  holds  the  uterus  in  place  in  even  the  most  difficult  cases,  the  body 
of  the  uterus  is  brought  out  between  the  bladder  and  the  vagina  as  shown  in 
Figure  94.  After  this  the  vaginal  outlet  is  built  up  as  in  the  operation  shown 
in  the  previous  figure. 

Treatment  of  Prolapsus. — While  retroflexion  and  simple  relaxation 
of  the  vaginal  outlet  are  easy,  prolapsus  is  often  exceedingly  difii- 
cult  to  cure.  The  flaccid  vaginal  walls,  with  a  loose  uterus  above,  are  apt  to 
roll  out  of  the  best-formed  vaginal  opening,  as  a  wet  glove  is  turned  inside 
out.  In  almost  all  cases  of  prolapsus,  a  series  of  operations  is  necessary  to 
effect  a  cure.     I  have  already  spoken  of  the  three  forms  of   pessaries   in  use 


334  DISPLACEMENTS    OF    THE    UTERUS. 

in  this  condition,  and  when  they  do  afford  relief  in  women  of  advanced  years, 
especially  in  those  who  are  very  stont,  it  is  far  better  to  use  them  than  to 
resort  to  any  more  or  less  aggressive  treatment.  A  pessary  cannot  be  used 
successfully,  however,  unless  there  is  a  more  or  less  well-formed  outlet  to  hold 
it  in.  If  there  is  a  fairly  good  outlet,  then  it  is  worth  while  to  spend  some 
little  time  in  persevering  effort  to  find  a  suitable  pessary. 

Whenever  there  are  ulcerations  on  the  everted  vaginal  mucosa, 
the  uterus  and  vagina  ought  to  be  pushed  back  into  the  pelvic  cavity  and  the 
ulcerated  surfaces  treated  by  inserting  glycerin  tampons,  and  keeping  the 
patient  in  bed  until  they  are  healed  (see  Fig.  S-4,  p.  323).  Each  time  the  tam- 
pon is  removed  a  prolonged  hot  douche  is  given,  six  quarts  of  water  as  hot  as 
can  be  borne  at  a  temperature  of  110°  to  116°  F.,  given  by  means  of  a  foun- 
tain syringe,  after  which  another  pack  is  inserted.  If  the  bladder  is  affected 
with  cystitis,  as  sometimes  happens,  it  should  be  treated  by  daily  irrigations 
with  a  boric  acid  solution  of  half  saturated  strength,  as  hot  as  can  be  borne. 
A  good  wav  to  do  this  is  to  attach  a  funnel  with  a  long  rubber  tubing  to  the 
end  of  the  catheter  and  after  filling  the  funnel  with  the  solution,  raise  it  two 
to  three  feet  above  the  level  of  the  patient  as  she  reclines  on  her  back.  Let 
the  fluid  run  into  the  bladder  until  the  patient  complains  of  gTcat  discomfort, 
then  pinch  the  tube,  and  disconnect  it  from  the  catheter.  Care  should  be 
taken  not  to  let  any  air  go  into  the  bladder,  as  it  is  apt  to  produce  distress. 
If  the  progTCSs  towards  recovery  is  not  rapid  enough,  the  boric  acid  solu- 
tion may  be  alternated  with  one  of  hot  nitrate  of  silver,  1 :  1000  in  strength. 
Should  these  means  fail  to  give  relief  the  patient  must  be  referred  to  a  spe- 
cialist with  a  view  to  operative  treatment. 


CHAPTEE    XIV. 

PELVIC  INFLAMMATORY  DISEASE. 
Definition,  p.  335.     Etiology,  p.  336.     Varieties,  p.  336.     Diagnosis,  p.  337.    Treatment,  p.  341. 

DEFINITION. 

The  term  "pelvic  inflammatory  disease"  is  applied  to  an  ex- 
tensive group  of  affections  of  an  inflammatory  nature,  involving  the  pelvic 
viscera.  The  result  of  such  an  inflammation  is  the  agglutination  of  the  con- 
tiguous viscera,  often  associated  with  the  formation  of  localized  swellings, 
consisting  of  abscesses  or  accumulations  of  serum,  which  are  walled  off  from 
the  rest  of  the  abdominal  cavity  above.  These  affections  are  so  exceedingly 
common  that  they  are  seen  by  every  general  practitioner,  and  their  treatment 
forms  a  large  part  of  the  surgical  work  which  the  gynecologist  is  called  upon 
to  do.  The  group  of  pelvic  inflammatory  diseases  is  subdivided  into 
a  number  of  specific  affections,  each  one  of  which  tends  to  differ  from  the 
others  in  its  mode  of  onset,  in  its  course,  and  in  its  termination;  the  group 
as  a  whole,  however  diverse  its  causes,  is  united  by  one  peculiarity,  namely, 
that  of  inflammatory  reaction,  which  results  in  the  formation  of  adhe- 
sions between  the  inflamed  structures  and  the  circumjacent 
peritoneum.     • 

In  the  first  broad  analysis  of  the  subject  inflammatory  affections 
may  be  divided  into  two  sorts:  one  which  is  infectious,  resulting  from  the 
invasion  of  pathogenic  organisms  ;  the  other  which  is  non-infectious 
and  results  from  the  irritative  action  of  some  chemical  product,  either  of  the 
uterine  tubes  or  of  the  ovaries,  upon  the  peritoneum,  provoking  an  inflam- 
matory reaction  without  the  formation  of  pus. 

The  non-infective  cases  of  pelvic  peritonitis,  as  a  rule,  arise 
from  the  ovaries  (excepting  in  the  case  of  a  tubal  hematocele)  ;  the  most  con- 
spicuous cases  of  this  class  are  the  extensive  hematomata  arising  from 
diseased  corpora  lutea.  The  blood  poured  out  under  these  circumstances 
provokes  violent  adhesive  inflammation  in  the  surrounding  peritoneum,  in 
which  both  ovaries  are  usually  involved,  being  walled  in  by  the  dense  attach- 
ments of  the  uterus,  tubes,  and  bowels  to  one  another. 

The  infectious  cases,  in  most  instances  in  which  the  avenue  of  inva- 
sion can  be  detected,  are  traceable  from  the  uterus  upwards,  through  the 
uterine  tubes,  and  so  onto  the  peritoneal  surfaces.  They  differ  from  the  non- 
335 


336  PELVIC    INFLAMMATORY    DISEASE. 

infective,  above  cited,  in  that  their  chief  seat  is  in  the  uterine  tubes^ 
which  may  show  extraordinary  changes,  becoming  converted  into  serous  or 
pus  sacs  (sacto-salpins),  sometimes  of  great  size. 

ETIOLOGY. 

The  inflammation,  whatever  its  cause,  is  usually  traceable  to  a  definite 
focus  where  it  resides  at  first,  and  from  which  it  extends  intermittently  to  the 
surrounding  structures.  The  focus  is  generally  manifest  in  the  greater  in- 
tensity of  inflammation,  and  the  greater  density  of  the  adhesions  at  this  point. 
It  is  important  to  note  the  fact  that  while  the  organ  which  forms  the  focus  of 
the  disease  is  often  injured  beyond  the  possibility  of  restoration,  the  adjacent 
organs  are  frequently  only  incidentally  affected,  being  involved  in  the  adhesions 
resulting  from  the  pelvic  peritonitis,  and  although  affected,  often  not  seriously 
injured  structurally. 

The  chronic  forms  of  pelvic  inflammation,  which  are  seen  for  the  most  part 
by  the  gynecological  specialist,  have,  as  a  rule,  been  progTessing  for  months, 
and  frequently  for  many  years ;  they  are  often  ambulatory,  visiting  one  oflice 
after  another,  and  clinic  after  clinic,  seeking  relief. 

The  acute  florid  forms,  on  the  other  hand,  are  oftener  seen  by  the 
general  practitioner,  who  is  called  in  where  there  is  a  fresh  gonorrhea,  and  in 
the  first  attack  of  pelvic  peritonitis ;  or  again,  he  sees  his  patient  through  her 
confinement,  and  then  watches  the  development  of  a  phlegmon  on  the  pelvic 
floor,  or  a  peritonitis  in  the  puerperal  period, 

VARIETIES. 

The  following  forms  of  pelvic  inflammatory  disease  are  those  com- 
monly seen: 

Gonorrheal  infection. 

Puerperal  infection.  ; 

Tubercular  infection. 

Corpus  luteum  cysts. 

Ectopic  pregnancy. 

Abscess  of  the  vermiform  appendix. 

Infected  dermoid  and  ovarian  tumors. 

This  is  purely  a  clinical  classification ;  a  more  scientific  division  based  bac- 
teriologically  on  the  infecting  organism,  is  the  following: 

(1)  The  gonococcus,  producing  gonorrheal  abscesses  in  the  tubes  or 
ovaries,  with  pelvic  adhesions. 

(2)  The  streptococcus,  seen  oftenest  in  puerperal  infections  and  com- 
monly invading  the  cellular  tissues  with  the  production  of  a  brawny  phlegmon. 

(3)  The    staphylococcus    and    the    colon    bacillus,    producing    ab- 


SYMPTOMS    AND    DIAGNOSIS.  337 

scesses  in  tlio  puerperal  period,  or  by  a  secondary  invasion  in  gonorrhea  and 
tuberculosis ;  as  well  as  from  an  infected  vermiform  appendix. 

(4)  Tlie  tubercle  bacillus,  causing  cheesy  and  nodular  tubes,  with 
more  or  less  extensive  dissemination  into  the  pelvic  peritoneum. 

(5)  The  group  of  non-infectious  inflammations,  already  referred  to. 

SYMPTOMS  AND   DIAGNOSIS. 

It  is  a  matter  of  the  utmost  importance  that  the  general  practitioner,  who 
handles  the  gross  materials  of  all  the  specialties  in  his  daily  practice  and  sep- 
arates such  as  need  further  elaboration  to  send  to  the  specialist,  should  recognize 
clearly  all  his  cases  of  pelvic  inflammatory  disease.  As  a  rule,  I  am 
sorry  to  say,  this  group  of  affections  is  not  promptly  recognized  to-day,  and  in 
many  instances  a  diagnosis  is  forced  upon  the  reluctant  practitioner  simply  by 
the  lapse  of  time,  and  by  the  fact  that  the  patient  continues  to  suffer  and  is 
failing  in  health,  in  spite  of  a  course  of  polypharmacy.  In  this  way  a  sort  of 
diagnosis  is  made  perforce,  which  is  not  creditable  to  the  medical  man,  and 
on  account  of  the  serious  loss  of  time,  is  often  injurious  to  the  patient.  It  is 
in  order  to  bring  the  practitioner  into  closer  touch  with  these  cases,  and  to  lay 
before  him  simple  and  satisfactory  methods  of  making  a  diagnosis,  without 
entering  into  unnecessary  refinements,  that  these  lines  are  written. 

Looking  at  the  pelvic  inflammatory  cases  symptomatically, 
there  are,  in  general,  two  groups,  the  non-sensitive  and  the  sensitive. 
One  of  these,  the  non-sensitive,  is  an  extraordinary  class,  in  which  there  may 
be  even  widespread  adhesions,  more  or  less  involving  all  the  jDclvic  organs,  but 
the  patient  may  liave  no  particular  discomforts  of  any  kind,  and  may  not  have 
complained  of  any  pelvic  disease  at  all,  until  some  irregularity  of  function, 
such  as  excessive  monthly  periods,  or  a  growing  mass  at  length 
forces  her  to  seek  advice.  At  present,  we  are  not  in  a  position  to  explain  the 
lack  of  pain  in  these  instances.  The  diagnosis  cannot  be  made  by  symptoms, 
for  there  are  few  or  none,  but  only  by  a  bimanual  examination  in  the  course 
of  a  routine  investigation,  when  the  adherent  masses  in  the  pelvis  will  be  dis- 
coverable. 

The  sensitive  group  are  those  suffering  from  pain,  which  in  prac- 
tically all  cases  is  present  at  the  menstrual  periods  and  which  in  the 
more  pronounced  cases  becomes  continuous  and  almost  unbearable. 

Tlie  pain  may  be  intermittent  or  continuous ;  at  times  it  is  excessive,  at 
others  but  slight,  or  altogether  absent.  Practically,  all  acute  cases  are  very, 
painful  from  the  start,  and  the  suffering  continues  until  the  disease  either 
disappears  or  subsides  into  a  chronic  state.  The  pain  is  usually  localized  in 
the  pelvis,  and,  as  a  rule,  the  painful  area  can  be  covered  by  the  palm  of  the 
hand  laid  upon  the  lower  abdomen  over  the  right  or  left  ovarian  re- 
gions.    On  the  right  side  the  pain  is  sometimes  located  near  enough  to  the 

brim  of  the  pelvis  posteriorly  to  cause  considerable  doubt  as  to  whether  or  not 
23 


338  PELVIC    IXFLAMMATOET    DISEASE. 

the  vermiform  ajDpendix  may  be  at  the  root  of  the  trouble.  When  the  pain 
becomes  intense,  it  is  apt  to  extend  over  the  whole  lower  abdomen,  into 
the  iliac  fossa,  and  down  one  of  the  legs,  following  the  anterior 
crural  and  sciatic  nerves,  or  into  the  lumbar  region  of  the  side  af- 
fected, in  other  words,  the  lower  abdomen  and  legs  are  involved. 

The  pain  due  to  a  bona  fide  pelvic  disease  differs  from  the  more  or  less  ill- 
defined  pains  of  a  hysterical  or  a  neurasthenic  patient,  in  that  the  inflammatory 
pain  has  a  definite  habitat.  The  pain  of  inflammation  is  a  fixed  pain;  it  is 
never  in  one  place  to-day  and  then  at  some  remote  part  of  the  body  to-morrow, 
one  day  perhaps  in  the  shoulder,  and  the  next  in  the  foot  or  the  calf  of  the 
opposite  leg,  etc.  It  is  a  safe  working  hypothesis  to  conclude  that  a  patient 
who  complains  of  a  definite  pain,  and  who  from  day  to  day  and  week  to  week 
is  definite  in  her  complaint  as  to  the  character  and  site  of  the  pain,  has  some 
gross  trouble.  This,  I  say,  is  a  safe  working  hypothesis.  It  is  not,  however, 
safe  to  operate  upon  a  patient  upon  such  an  indication;  but,  given  such  a 
definite  complaint,  I  would  give  the  patient  an  anesthetic,  carefully  examine 
the  pelvic  organs,  and  clear  up  the  diagnosis  in  that  way.  As  a  rule,  the 
pelvic  inflammatory  pain  is  gradually  increased  at  the  menstrual 
periods,  becoming  sharper  with  the  congestion  of  the  organs;  in  some  cases 
it  becomes  intolerable  at  this  time,  but  it  is  possible  that  the  pain  is  not  felt 
at  all  at  the  periods.  In  many  instances,  the  pain  is  continuous,  dull, 
aching,  grinding,  tearing  in  character,  with  exacerbations  brought 
about  by  exercise,  fatigue,  etc.  A  sense  of  burning  in  the  abdomen, 
often  noted  on  the  left  side,  over  the  pelvis  or  above  it,  is  commonly  associated 
with  a  neurosis  without  objective  changes. 

Fever  is  a  variable  factor;  when  there  is  no  pus,  there  is,  as  a  rule,  no 
fever,  or  at  most  but  slight  elevations  of  temperature.  When  there  is  an  acute 
infection  or  an  exacerbation  of  an  old  infection  associated  with  fever,  there  is 
an  increase  in  the  number  of  white  blood  cells  in  the  blood  (leucocytosis),  from 
the  normal  seven  to  nine  thousand  wp  to  fifteen  to  thirty  or  more  thousand. 
This  leucocytosis  is  gTeater  in  the  puerperal  than  in  the  gonorrheal  infections, 
and  runs  a  course  fairly  pa.ralleling  the  febrile  curve.  The  absence  of  leuco- 
cytosis does  not  show  the  absence  of  an  abscess  in  the  pelvis. 

When  pus  is  present,  and  the  process  is  not  acute,  there  may  also  be  no 
fever  at  all,  or  an  elevation  of  only  one  half  or  one  degTee.  With  the  extension 
of  an  infection  from  a  focus  of  su]3puration,  however,  the  patient  may  run  an 
acute  febrile  course  for  some  days  or  weeks.  Fever  is  found  in  all  acute  cases, 
varying  in  intensity  with  the  character  of  the  infection,  and  being  most  intense 
in  the   streptococcus   puerperal  patients. 

In  making  a  diagnosis  of  a  pelvic  inflammatory  disease,  close 
attention  must  be  paid  to  the  history,  and  often  from  this  alone  such  strong 
presumptive  evidence  may  be  gathered,  that  a  fairly  accurate  conjecture  can 
be  made. 

In  an   acute   case  the  cause,  as  a  rule,  is  all  too  obvious;  a  young  women 


SYMPTOMS    AND    DIAGNOSIS.  339 

comes  to  her  plivsician  with  a  free  purulent  vaginal  discharge,  the  external 
parts  may  be  more  or  less  inflamed,  and  the  cervix  pouring  out  some  secretions. 
After  suffering  from  such  symptoms  for  a  few  days  or  longer,  she  is  seized 
with  severe  cramplike  abdominal  pains,  with  fever  and  great  tenderness  over 
the  lower  abdomen,  so  that  she  is  obliged  to  go  to  bed.  Or  it  may  be  that  a 
young  married  woman  comes  with  the  same  history ;  the  doctor  discreetly  takes 
the  husband  aside  and  asks  him  if  he  had  any  gonorrheal  disease  at  marriage, 
and  he  acknowledges  an  infection  a  few  months  back,  but  says  his  doctor  dis- 
charged him  cured,  after  a  brief  treatment.  Again,  the  same  history  repeats 
itself  after  a  menstrual  period,  when  the  portals  for  infection  are  thrown  open 
through  the  increased  congestion  and  succulence  of  the  mucous  membranes.  The 
same  sort  of  an  infection  is  also  prone  to  occur  in  the  puerperal  period. 

The  examination  in  acute  cases  reveals  great  tenderness  at  the  vault  of  the 
vagina  and  the  most  delicate  manipulation  shows  that  this  extends  out  laterally 
over  the  pelvic  floor.  In  one  and  all  of  these  cases  there  is  an  acute  gonorrheal 
process  at  work.  The  history  points  to  the  diagnosis,  and  the  microscopical 
examination  of  the  secretions,  showing  intracellular  diplococci  in  the  pus 
cells,  proves  it  beyond  question.  A  gonorrheal  infection  may  be  inferred 
in  cases  of  women  of  loose  life,  who  are  continually  exposed  to  infection ;  or  it 
may  be  suggested  in  married  women  by  circumstances  relative  to  the  condition 
and  habits  of  the  husband,  known  only  to  the  physician.  In  the  unmarried, 
pelvic  inflammatory  disease  is  very  apt  to  be  due  either  to  gonorrhea  or 
tuberculosis.  If  the  moral  character  is  above  suspicion,  tuberculosis  or 
corpus  luteum  cysts  must  be  seriously  considered.  A  gonorrheal 
infection  may,  as  a  rule,  be  proven  from  the  character  of  the  cervical  dis- 
charge, and  sometimes  from  the  enlargement  of  the  vulvo-vaginal  glands ;  or 
from  a  lingering  infection  in  the  urethral  glands,  in  which  pus  is  easily 
squeezed  out  by  a  little  pressure  under  the  pubic  arch ;  or  it  may  be  shown  by 
the  vaginal  secretions,  or  from  recrudescences  of  vaginitis,  in  which  the  gono- 
cocci  become  evident.  Whenever  it  is  possible,  a  little  of  the  cervical  secre- 
tion should  be  thinly  smeared  on  a  glass  slide  and  examined  under  the  micro- 
scope. If  the  general  practitioner  is  not  prepared  to  do  this  he  can  send  the 
slide  by  mail  to  some  one  who  is  competent  (see  p.  276). 

Puerperal  cases  often  date  from  a  bad  labor  with  protracted  use  of 
forceps,  followed  by  fever,  and  a  slow  getting  up.  These  also  are  often  gonor- 
rheal in  nature.  If  the  examination  of  the  discharge  shows  the  absence  of  such 
a  specific  organism  as  the  gonococcus,  one  of  the  staphylococci  is  prob- 
ably at  fault.  The  patient  often  comes  with  the  definite  statement  that  she  has 
not  been  well  since  her  last  labor,  or  since  a  miscarriage. 

Tuberculosis  may  often  be  suspected  from  the  body  habit,  from  the  ex- 
istence of  tuberculosis  elsewhere,  from  the  family  tendency;  it  may  be  associ- 
ated with  the  uterine  discharge  and  proven  by  curettage,  and  the  finding  of 
tuberculosis  of  an  endometrium.  Tuberculosis  is  apt  to  affect  women  in  the 
first  half  of  life  who  have  not  borne  children. 


340  PELVIC    I]SrFLA:MMATOEY    DISEASE. 

When  curettage  is  performed  in  pelvic  inflammatory  disease,  the  operator 
must  be  careful  not  to  rupture  any  adhesions  or  to  open  an  abscess  by  tractions 
on  the  uterus.  If  there  are  any  lateral  masses  the  uterus  ought  never  to  be 
pulled  upon.  If  it  is  curetted,  this  should  be  done  with  the  organ  remaining 
in  situ  and  with  as  little  disturbance  as  possible. 

Corpus  luteum  cysts  have  a  tendency  to  rupture  and  pour  blood  into 
the  cul-de-sac  of  Douglas,  thus  exciting  an  inflammatory  reaction  and  leading 
to  the  formation  of  large  adherent  masses.  An  exactly  similar  process  follows 
the  rupture  of  extra-uterine  pregnancy  leading  to  the  formation  of 
the  once  much  discussed  hematocele. 

Disease  of  the  Vermiform  Appendix. — The  physician  must  always 
bear  in  mind  that  pelvic  inflammatory  disease  is  associated  in  not  a  few  cases 
with  disease  of  the  appendix.  This  point  is  an  important  one,  as  the  expectant 
plan  of  treatment  is  not  suitable  in  cases  where  the  appendix  is  concerned. 
This  subject  is  more  fully  discussed  in  Chapter  XXIV. 

A  further  group  of  inflammatory  affections,  often  bilateral,  are 
associated  with  the  small  dermoid  cysts,  which  may  provoke  a  most  vio- 
lent inflammatory  reaction.  Dermoid  cysts  at  every  period  of  their  growth  are 
peculiarly  liable  to  provoke  a  non-infectious  irritative  peritonitis  with  dense 
adhesions  to  the  contiguous  structures.  These  cases  offer,  perhaps,  as  good  an 
example  as  could  be  found  of  a  well-defined  peritonitis  in  the  absence  of  any 
micro-organisms.  The  invasion  of  the  cyst  by  organisms  is  associated  with 
febrile  disturbances,  increased  pain,  and  the  formation  of  pus. 

Papillary  cysts  also  form  a  peculiar  group,  almost  always  bilateral,  in 
which  the  ovaries  grow  as  large  as  the  fist,  and  are  filled  with  a  mucilaginous 
material  and  papillary  outgrowths  which  soon  perforate  the  thin  sac  walls  and 
spread  on  to  the  surrounding  peritoneum.  These  cysts  almost  invariably  pro- 
voke a  violent  inflammatory  adhesive  reaction.  After  taking  a  careful  history 
and  trying  to  get  presumptive  evidence  of  some  one  of  these  causes,  the  bi- 
manual examination  is  made. 

While  a  history  of  a  fixed  pain  with  exposure  to  infection,  associated  with 
or  without  vaginal  discharge,  may  lead  to  a  diagnosis  of  pelvic  inflammatory 
disease,  such  a  diagnosis  can  never  be  made  with  certainty  until  the  disease  is 
directly  recognized  by  the  examining  finger.  Upon  introducing  one  or  two 
fingers,  the  cervix  may  at  once  be  noted  to  be  immovable  or  rel- 
atively immovable.  Carrying  the  finger  a  little  farther  up,  a  distinct  swelling 
at  the  vaginal  vault,  posterior  and  lateral  to  the  cervix,  may  make  the 
diagnosis  positive  within  a  few  seconds,  even  without  any  further  investigation. 
Any  swelling  which  is  felt  in  this  way  by  the  vagina  can  also  be  more  distinctly 
felt  through  the  empty  rectum  as  the  finger  enters  the  narrowed  channel,  back 
of  the  swelling,  and  is  carried  on  above  over  its  rounded,  posterior  eminences, 
which  separate  the  finger  from  the  uterus.  If  these  distinct  signs  of  inflam- 
matory trouble  are  not  readily  found,  it  is  well  to  suggest  an  examination  under 
anesthesia.     For  the  purpose  of  making  a  most  complete  anesthetic  examina- 


SYMPTOMS    AND    DIAGNOSIS.  341 

tion,  it  is  often  sufficient  to  give  the  patient  nitrous  oxide  gas,  but  the  addition 
of  a  little  ether  may  be  necessary  in  many  instances  to  secure  a  complete  relaxa- 
tion. When  the  patient  is  under  gas  with  the  bowels  well  emptied,  the  cervix 
is  caught  by  the  tenaculum  forceps  and  drawn  carefully  down,  pulling  the 
body  of  the  uterus  with  it,  while  the  finger  is  introduced  into  the  rectum,  and 
by  invagination  of  the  perineum,  carried  as  higli  up  in  the  pelvis  as  possible, 
to  some  point  not  far  below  the  promontory  of  the  sacrum.  With  the  vaginal 
finger  or  fingers  thus  hooked  around  the  uterus,  tubes,  and  ovaries,  and  used 
as  a  sensitive,  posterior  plane  ready  to  recognize  any  transmitted  motion  and 
any  varying  degrees  of  hardness  in  structure,  the  upper  or  abdominal  hand  is 
used  to  make  pressure  upon  the  various  pelvic  structures  and  bring  them  within 
the  reach  and  touch  of  the  fingers  in  the  rectum.  In  this  way,  the  uterine  body 
is  outlined,  the  posterior  surfaces  of  the  broad  ligaments  are  palpated,  the 
ovaries  are  clearly  felt,  and  the  examiner  has  the  assurance  that  if  there  were 
any  enlargement  of  the  uterine  tubes,  they  would  be  felt  also.  Where  an 
abscess  is  suspected  he  must  be  careful  not  to  drag  the  uterus  far  down,  and 
not  to  use  force  in  touching  the  lateral  structure,  for  fear  of  rupturing  it. 

The  simplest  form  of  pelvic  infiammatory  disease  which  can  be  found  is 
an  adherent  ovary.  To  find  this  the  physician  must  so  far  have  mastered 
the  technic  of  the  bimanual  examination  that  he  is  able  to  recogTiize  and  handle 
a  normal  ovary  per  rectum.  The  posterior  surface  of  the  uterus  and  the  fundus 
being  large  objects  are  easily  found  with  a  little  practice ;  then,  feeling  gently 
out  to  the  right  or  left  of  the  cornu  uteri  just  under  the  angle,  the  utero-ovarian 
ligament  is  first  felt,  and  then,  following  this  outwards,  the  ovary  itself.  It  is 
hard,  slightly  irregular,  or  a  little  nodular,  perhaps^  contains  a  large  follicle, 
from  two  to  three  centimetres  in  diameter  and  always  movable.  If  the 
ovary  is  adherent,  it  cannot  be  lifted  from  its  bed,  or  else  the  little  string-like 
adhesions  are  felt  to  snap  as  it  is  freed.  Uterine  tubes  only  lightly  adherent, 
and  not  otherwise  altered,  cannot  be  felt. 

It  is  most  important  to  distinguish  these  pelvic  inflammatory  cases  from 
cases  of  a  sensitive  pelvic  peritoneum.  It  is  not  uncommon  to  see  women  who 
complain  of  extreme  pain  when  any  portion  of  the  pelvic  peritoneum  is  touched. 
For  example,  when  a  perfectly  normal  uterus  is  being  palpated  bimanually, 
they  cry  out  with  severe  pain.  This  fact,  namely,  that  the  pain  is  complained 
of  when  normal  structures  are  under  touch,  ought  to  put  the  examiner  on  his 
guard,  so  that  he  will  attribute  a  like  importance  to  the  same  complaints  uttered 
when  the  structures  lateral  to  the  uterus,  which  cannot  be  so  clearly  outlined, 
are  under  examination.  It  will  be  seen  from  this  that  it  is  never  safe  to  make 
a  diagnosis  from  pain  alone. 

TREATMENT. 

Prophylaxis. — There  is  but  little  use  in  uttering  any  warnings  regarding 
the  gonorrheal  affections,  as  they  are  introduced  under  circumstances 
over  which  the  temperate  advice  of  the  physician  has  practically  no  control. 


342 


PELVIC    IXFLAMilATORY    DISEASE. 


This  aspect  of  the  question  rests  largely  in  the  hands  of  those  parents  and 
educators  who  look  at  the  formation  of  character  and  a  chivalrous  respect  for 
woman  as  the  chief  factors  in  an  education.  Puerperal  infection  will  be 
avoided  by  aseptic  conduct  of  labor  and  the  puerperium,  as  described  in  Chap- 
ter XIX.  Over  the  tubercular  affections,  the  corpus  luteum  cysts, 
and  the   neoplasms    of   the    ovary,    we  can  also  exercise  no  control. 

Forms  of  Treatment. —  Treatment  may  be  expectant,  or  palliative,  or 
radical.  In  the  acute  forms  there  is  rarely  any  call  for  active  radical 
interference  in  the  earliest  stages.  ^Tiere  the  highest  skill  is  available,  how- 
ever, it  is  sometimes  possible  to  cut  short  an  acute  attack,  where,  for  example, 
there  is  a  gonorrheal  infection  of  the  tubes,  by  opening  the  posterior  cul-de-sac, 
and  draining  the  peritoneum  freely.  This  plan  of  treatment  has  been  devised 
and  successfully  carried  on  by  that  able  gynecologist,  the  late  Dr.  F.  Henrotin 
of  Chicago  (Trans.  Amer.  Gyn.  Soc,  1895,  vol.  20,  p.  232).  In  the  more 
acute  conditions,  and  where  there  is  no  fever  at  all,  rest  is  the  sheet 
anchor  in  the  treatment.  The  patient  ought  to  be  flat  on  her  back  in  bed,  and 
the  bowels  ought  to  be  kept  emptied.  Prolonged  hot  saline  douches  may 
be  given,  making  the  temperature  of  the  douche  as  near  120°  P.  as  the  patient 
can  comfortably  bear  it.    A  tablespoonful  of  salt  may  be  added  to  the  quart  of 

water,  and  the  douche  continued  for  from  ten 
to  twenty  minutes.     Patients  who  are  suffer- 
ing  severely   sometimes    derive    great   relief 
from    poultices    on  the  abdomen.     Where 
there  is  a  painful  swelling  on  the  lower  ab- 
domen, an    ice-bag    over  it  with  a  towel  intervening 
serves  to  restrain  the  inflammatory  process  and  gives 
much  comfort.     In  a  more  acute  case,  where  there  is 
manifest  fluctuation,  the   vaginal   vault   should   be 
opened.     This  is  best  done  by  bringing  the  patient  to 
the  edge  of  the  bed  or  side  of  the  table,  with  legs  flexed 
on  the  abdomen ;  the  cervix  is  then  exposed  by  retracting 
the  posterior  vaginal  wall,  grasped,  and  held  forwards, 
while  the  vault  of  the  vagina,  just  behind  the  cervix,  is 
opened  with  a  pair  of  scissors  from  side  to  side.     The 
peritoneum  is  soon  visible  just  above  the  incised  vagina 
(Fig.    95),  and  this  is  also  carefully  opened,   at  once 
effecting  an  entrance  into  the  abscess,  or  else  exposing 
its  wall  which  is  laid  widely  open.    After  all  the  pus  is 
evacuated,  the  cavity  may  be  thoroughly  wiped  out  with 
a  pledget  of  gauze,  grasped  in  a  pair  of  long  forceps, 
after  Avliieh  it  is  loosely  packed  with  an  iodoform  gauze 
drain.      The   opening  into   the  vaginal  vault  tends   to 
close  rapidly.     It  may  have  to  be  enlarged  once  or  twice  in  the  course  of  the 
convalescence,  however,  before  the  abscess  cavity  has  completely  collapsed. 


Fig.  95.  —  The  Vaginax, 
Vault  is  Exposed  and 
THE  Cervix  Caught  by 
A  Stout  Forceps  and 
Held  a  Little  For- 
ward WHILE  ax  Ellipti- 
cal Ixcisiox  is  Made 
Posterior  to  the  Cer- 
vix. Through  this  incis- 
ion the  peritoneum  is 
opened  and  the  abscess 
evacuated.  (From  Kelly- 
Noble  "  Gynecology  and 
Abdominal  Surgerv," 
1907,  Vol.  I.) 


FOEMS    OF    TREATMENT.  343 

In  a  case  which  is  clearly  and  beyond  peradventure  improving,  the  physician 
is  warranted  in  waiting  from  week  to  week,  keeping  the  patient  under  close 
observation.  In  a  case  which  does  not  improve,  or  which  grows  worse,  he 
should,  after  making  a  careful  diagnosis,  seek  the  advice  of  a  specialist  in  ab- 
dominal surgery,  either  a  gynecologist  or  a  general  surgeon,  and  consider  the 
question  of  a  more  radical  oiDcration,  either  by  the  vagina  or  by  the  abdo- 
men. It  is  not  our  province  here  to  enter  upon  the  technic  of  these  radical 
operations. 

The  treatment  in  a  chronic  case  is  either  operative  or  non- 
operative.  All  those  cases  should  be  operated  upon  in  which  there  is  a  demon- 
strable abscess,  or  any  large  mass  or  masses,  within  the  pelvis.  It  is  important 
to  do  this,  and  to  do  it  without  delay,  as  the  inflammatory  cases  with  masses  or 
tumors  to  the  right  and  to  the  left  in  the  pelvis  are  liable  to  exacerbations 
with  rupture  in  the  direction  of  the  peritoneum,  or  into  the  bowel,  or  the  blad- 
der. Every  case  in  which  any  lumpy  or  resistant  areas  are  felt  to  the  one  side 
or  the  other  should  be  looked  upon  as  probably  operative  and  referred  to  a 
specialist  for  an  opinion. 

The  utmost  that  can  be  done  for  the  non-operative  cases  is  to  wait  awhile 
to  see  if  ISTature  cannot  relieve  all  the  symptoms  and  cure  the  disease  her- 
self. ISTature's  great  coadjutor  in  bringing  this  result  about  is  Time.  While 
waiting  for  the  beneficial  effects  which  are  to  accrue  from  time,  the  physician 
must  exercise  an  intelligent  supervision,  watching  the  subsidence  of  the  trouble 
from  week  to  week,  with  gentle  examinations  from  time  to  time,  meanwhile 
prescribing  such  a  regimen  as  will  promote  the  end  in  view,  while,  at  the 
same  time,  he  restrains  the  patient  from  doing  those  things  which  will  be 
likely  to  prove  harmful.  To  these  ends  he  enjoins  much  rest,  late  rising,  and 
early  bedtime,  and  rest  for  an  hour  after  meals,  forbidding  active  exercise 
and  late  hours.  He  must  also  see  that  the  lower  bowel  never  becomes  clogged. 
Hot  vaginal  douches  of  plain  hot  water  with  table  salt  (two  teaspoonfuls  to  a 
pint),  once  a  day  for  say  ten  to  fifteen  minutes  at  a  time,  are  often  both  re- 
freshing and  helpful.  Some  patients  are  helped  by  painting  the  vaginal  vault 
with  a  strong  tincture  of  iodine  (Churchill's)  about  once  a  week,  follow- 
ing this  with  a  boroglycerid  pack.  This  is  done  by  nesting  a  teaspoonful 
of  boroglycerid  in  a  pledget  of  absorbent  cotton,  the  size  of  the  palm  of  the 
hand,  tied  with  a  string,  folding  this  together,  and  placing  it  against  the  vaginal 
vault.  The  pack  is  removed  in  twelve  hours  by  pulling  on  the  string  which 
hangs  outside.  I  would  repeat  these  packs  about  every  third  day.  A  douche 
must  not  be  given  while  the  pack  is  in  the  vagina. 

Massage  should  not  be  given  to  the  lower  abdomen,  although  general 
massage  is  useful.  Electricity,  I  believe,  is  of  no  service.  When  a  case 
does  not  promptly  improve,  a  specialist  must  be  asked  to  see  it ;  by  neglecting 
to  do  this  a  malignant  tumor  may  be  encouraged  to  groAv,  or  a  case  of  pelvic 
inflammatory  disease  arising  from  the  vermiform  appendix  may  be  overlooked 
and  allowed  to  grow  worse, 


344  PELVIC  ijstflammatory  disease. 

ManN'  of  the  cases  of  pelvic  inflammatory  disease  are  due  to  tuberculosis 
which  cannot  get  better  until  the  disease  is  removed  by  surgery. 

I  ^vish  especially  to  call  the  attention  of  the  practitioner  to  the  pro- 
priety of  conservatism  in  many  of  these  cases  which  come  to  operation.  It 
is  always  comparatively  easy  to  do  a  radical  operation,  that  is  to  say,  to  take 
out  both  tubes  and  ovaries;  but  a  more  restricted  removal  of  the  diseased 
organs  only,  will  conserve,  at  least,  the  function  of  ovulation  and  internal 
secretion,  and  it  may  be  that  of  conception  too,  thus  saving  the  patient  much 
distress  of  mind  and  avoiding  tlie  disagreeable  sequelae  of  the  extirpative 
treatment. 

It  sometimes  happens  that  the  physician,  though  he  may  not  know  as  much 
as  the  specialist,  is  yet  better  able  to  safeguard  the  best  interests  of  the  patient, 
even  on  the  operating  table.  This  he  can  do  in  two  ways,  in  the  group  of 
affections  under  consideration.  In  large  abscesses  he  may  cast  his  vote  in  the 
consultation  in  favor  of  pelvic  drainage  by  the  vaginal  route.  Paradoxical  as 
it  may  seem,  the  worst  cases  sometimes  get  well  in  this  way,  with  a  good  drain 
in  the  vault  of  the  vagina,  quicker  than  some  of  the  apparently  simpler  cases 
which  cannot  be  drained.  At  any  rate,  a  patient  with  a  big  abscess  can  often 
be  drained  with  perfect  safety,  when  it  would  be  most  hazardous  to  attempt  a 
complete  extirpation.  Later,  if  she  needs  it,  the  extirpation  can  be  done  with 
safety  in  the  absence  of  pus. 

Again,  the  attending  physician  may  be  called  upon  to  decide  for  or  against 
conservatism.  To  make  an  intelligent  decision  he  must  bear  in  mind  the  fact 
that  in  all  cases  of  pelvic  inflammatory  diseases  the  ovaries  are  involved  in 
adhesions  simply  because  of  the  accident  of  their  location  close  to  the  fimbriated 
extremities  of  the  tubes,  out  of  which  the  infectious  materials  are  poured  into 
the  peritoneum.  When  the  disease  is  of  long  standing,  and  the  ovaries  are 
withered  through  compression  from  the  inflammatory  exudate  in  which  they  lie 
embedded,  it  is  of  no  use  trying  to  save  them.  When  the  adhesions  are  not  so 
bad,  and  the  ovary,  freed  from  its  bed,  appears  comparatively  healthy,  it  may 
be  saved  with  the  assurance  that  it  will  continue  to  carry  on  its  functions  per- 
fectly, even  though  the  tube  has  to  be  removed.  Conservatism  of  the  tubes  in 
pelvic  inflammatory  disease  is,  as  a  rule,  misdirected  energy,  but  ovarian  con- 
servatism is  well  worth  while. 

If  the  patient  is  excessively  anxious  for  offspring,  the  uterine  tube  may  be 
amputated  and  its  end  left  patulous.  If  then  the  ovary  is  not  removed,  at 
least  a  hope  of  conception  is  preserved,  and  this  serves  to  ward  off  the  distress 
of  mind  which  would  otherwise  darken  the  life.  If  the  whole  ovary  cannot  be 
kept,  a  piece  may  be  retained.  If  a  good  ovary  is  kept  on  one  side  and  a  good 
tube  in  the  other,  there  is  a  fair  hope  of  conception  taking  place. 

When  an  ovary  is  the  seat  of  a  hematoma,  and  buried  in  a  mass  of  adhesions, 
being  itself  converted  into  a  mere  shell,  the  uterine  tube  belonging  to  it,  and 
the  uterus  when  liberated  from  the  adhesions,  may  prove  entirely  normal  or  else 
capable  of  perfect  regeneration  and  restoration  to  normal  fuuetiraial  activity. 


CONSERVATISM    IN    TREATMENT.  345 

When  both  ovaries  form  adherent  hematomata,  conservatism,  as  a  rule,  is  not 
worth  while. 

In  considering  conservatism  these  facts  must  be  borne  in  mind : 

(1)  It  is  useless  to  run  risks  of  a  continuance  of  the  troubles  from  which 
the  patient  is  suffering,  for  the  sake  of  preserving  the  menstrual  function,  if 
she  is  forty  years  old  or  more. 

(2)  If  the  patient  is  single  and  middle-aged,  without  any  expectation  of 
marriage,  the  exercise  of  conservatism  is  less  important. 

(3)  If  the  patient  has  to  labor  for  her  own  living,  it  is  best  not  to  take  too 
many  chances  of  the  return  of  the  disease  by  leaving  any  crippled  structures. 

(4)  It  is  dangerous  to  save  tubes  containing  purulent  or  milky  fluid.  An 
old  and  apparently  harmless  salpingitis  has  been  opened  up,  and  the  tube 
cleansed  and  dropped  back  into  the  pelvis,  and  this  has  resulted  in  the  death 
of  the  patient. 

(5)  If  the  patient  wants  above  all  things  to  be  well,  then  the  physician 
will  be  less  inclined  to  take  chances  with  conservatism. 

(6)  As  a  rule,  the  results  of  conservatism  are  disappointing,  and  the  patient 
ought  always  to  be  forewarned  that  it  may  be  necessary  to  repeat  the  operation, 
and  to  make  it  more  radical,  if  the  first  conservative  effort  proves  a  failure. 

When  and  what  to  conserve  in  recent  cases,  and  when  and  what  not  to  con- 
serve is  a  matter  of  fallible  judgment;  hence  the  common  failures,  even  in  the 
most  experienced  hands. 


CHAPTEE    XV. 

STERILITY. 

Definition,  p.  346.  National  importance,  p.  347.  Development  of  knowledge  on  the  subject, 
p.  350.  Etiologj' in  themale,  p.  351.  Etiology  in  the  female,  p.  357.  Diagnosis  and  treat- 
ment, p.  369. 

DEFINITION. 

Steeiltty  is  a  disease  of  married  life  aifecting  the  generative  and  procre- 
ative  pcAvers  of  the  contracting  parties,  so  that  the  marriage  remains  fruitless. 
If  either  husband  or  wife  is  incapable  of  procreation,  the  effect  is  the  same  as 
though  both  were  affected. 

Sterility  is  absolute  when  an  individual  has  utter  incapability,  and 
relative  when  the  difficulty  is  removable  and  there  is  a  possibility  of  off- 
spring, if  only  the  partner  is  sound.  Some  women  are  sterile  because  their  part- 
ners are  incapable  of  procreation.  Sterility  is  relative  or  facultative 
when  brought  abotit  by  voluntary  sexual  abstinence  or  by  practices  which  pre- 
vent conception.  That  wedlock  also  is  jDractically  sterile  in  which,  though  con- 
ception frequently  occurs,  the  product  is  cast  off  in  an  unnatural  state  by 
abortion  or  miscarriage. 

It  is  of  the  utmost  importance  to  distinguish  between  male 
and  female  sterility,  and  the  most  notable  advance  in  our  knowledge  of 
the  subject  within  the  past  generation  has  been  due  to  a  careful  discrimination 
in  this  respect.  For  example,  when  a  wife  appeals  to  a  physician  for  relief  of 
sterility,  he  does  not  now  commit  the  blunder  of  focussing  his  attention  upon 
her  alone,  but  insists  upon  a  careful  investigation  of  the  procreative  powers  of 
the  husband  as  well. 

One-Child  Sterility. — There  is  one  special  and  important  form  of  sterility, 
known  as  '"  one-child  sterility,"  in  which  a  woman  conceives  promptly  after 
marriage,  and  then  never  does  so  again.  Sometimes  the  reason  is  not  discover- 
al)lc.  V)Ut  the  majority  of  such  cases  arise  from  puerperal  infection;  or  a  latent 
gonorrhea,  recrudescent  in  tlie  puer]Teral  state;  or  a  fresh  gonorrhea  acquired 
from  the  incontinent  husband.  Again,  a  fibroid  tumor  starts  to  grow  and  in- 
terferes with  future  conceptions.  In  rare  cases  there  is  an  atrophy  of  the  uterus 
with  more  or  less  amenorrhea.  The  causes,  as  a  rule,  are  not  difficult  to  eluci- 
346 


NATIONAL    IMPORTANCE.  347 

date  after  a  careful  history  has  been  taken  and  a  pelvic  examination  has  been 
made. 

Sterility  is  an  affection  which  may  be  congenital  or  acquired,  as,  for 
example,  in  the  male  a  congenital  sterility  may  be  associated  with  cryptorch- 
ism  or  epispadias,  while  an  acquired  sterility  may  be  due  to  gonorrhea. 
In  the  wife  the  congenital  form  may  be  due  to  imperfect  development  of 
the  internal  genital  organs,  the  acquired  to  pelvic  inflammation.  A  woman  is 
presumptively  sterile  who  has  not  become  pregnant  within  the  first  three  years 
of  married  life. 

NATIONAL   IMPORTANCE. 

The  question  of  sterility  is  a  problem  of  the  highest  national  importance, 
for  upon  the  fertility  of  the  dual  units  (husband  and  wife)  which  go  to  make 
up  the  body  politic  depends  the  healthy  national  life.  All  wealth,  all  that  is 
best  in  art  and  science,  all  precious  stores  of  tradition  may  become  worse 
than  useless,  a  mere  mockery  of  what  might  have  been,  if  accompanied  by  a 
progressive  sterility.  Dr.  Hunsberger  has  shown  in  an  article  on  "  Race 
Suicide  "  {Jour.  Amer.  Med.  Assoc,  Aug.  10,  1907)  that  among  families  which 
can  properly  have  children  the  population  will  not  materially  increase  if  there 
are  fewer  than  four  children  to  each  pair.  The  intention  of  the  Creator  ex- 
pressed to  the  first  pair  in  the  primal  command  coupled  with  the  first  bless- 
ing (Gen.  i:28)  is  rendered  nugatory  by  sterility.  Fertility  is  the  natural 
outcome  of  right,  clean  living.  Such  a  condition  as  a  congenital,  unavoidable 
sterility  in  either  sex  is  rare  ;  a  vast  amount  of  that  decadence  which  con- 
stitutes a  national  problem  is  of  the  avoidable  kind,  and  such  sterility  is 
almost  Avithout  exception  volitional ;  that  is  to  say  dependent  upon  illicit  sexual 
relations. 

In  tliis  way  the  percentage  of  sterility  is  an  index  to  the  morals  of  a  na- 
tion. If  the  birth  rate  sinks  below  the  death  rate  of  a  community,  immoral- 
ity and  vice  of  all  sorts  prevail,  and,  looked  at  from  this  standpoint,  it  will 
at  once  be  seen  that  the  treatment  of  sterility,  when  the  disease  is  marked 
enough  to  affect  national  statistics,  is  a  deep  and  a  difficult,  if  not  a  hopeless 
problem. 

Drs.  Newsholme  and  Stevenson  {Jour,  of  the  Roy.  Statistical  Soc,  Mar., 
1906)  have  an  interesting  paper  on  this  subject  in  which  they  point  out  as  a 
source  of  declination,  not  increased  poverty  but  the  propagation  of  "  the  gospel 
of  comfort,"  which  is  becoming  the  ethical  standard  for  all  civilized  nations. 
Also  the  increasing  practice  of  artificial  prevention  must  mean  a  lower  moral 
standard,  because  the  increasing  fertility  in  such  poor  countries  as  Ireland 
and  ISTorway  hardly  accords  with  the  attempt  to  explain  sterility  on  economic 
grounds.  ISTor,  they  further  remark,  is  the  decline  due  to  physical  degenera- 
tion affecting  the  generative  powers  a  cause  of  decrease  in  fecundity.  The 
presumption  is  that  the  fall  is  due  to  conditions  within  the  control  of  the  peo- 
ple— a  social  form  of  felo-de-se.     The  following  table,  prepared  by  Dr.  Jacques 


348 


STERILITY. 


Bertillon,  is  quoted  as  to  tlie  annual  births  per  1,000  women,  aged  fifteen  to 


fifty,  in  four  cities 


Classification. 


Paris. 


Berlin. 


Vienna. 


London. 


Very  poor  quarters 

Poor  quarters 

Comfortable  quarters 

Very  comfortable  quarters 

Rich  quarters 

Very  ricli  quarters 

Average 


104 
95 
72 
65 
53 
34 


157 

129 

114 

96 

63 

47 


200 
164 
155 
153 
107 
71 


197 
140 
107 
107 
87 
63 


80 


102 


153 


109 


The  general  conclnsion  arrived  at  is  that  as  the  decline  seemed  almost  uni- 
versal and  "  people  did  not  change  their  morality  in  a  large  number  of  different 
countries  at  a  given  time  without  some  extremely  definite  cause,"  a  strong 
economic  factor,  that  is,  "  the  gospel  of  comfort,"  was  in  reality  the  deter- 
mining one. 

Among  the  most  valuable  works  dealing  with  this  question  from  a  broad 
standpoint  is  one  by  Matthews  Duncan  ("  Sterility  in  Women."  J.  A. 
Churchill,  London,  1884).  Duncan  found  that  even  among  the  better  class 
sterility  was  increasing.  Five  hundred  and  forty  absolutely  sterile  women  con- 
sulted him  within  five  years.  These  had  been  married  between  the  ages  of 
fifteen  and  forty-two,  and  three  hundred  and  thirty-seven  had  been  wives  over 
three  years.  He  has  considerable  confidence  in  stating  one  in  ten  as  very  nearly 
the  true  amount  of  sterility  of  marriages  in  Great  Britain ;  for  women  delaying 
the  commencement  of  fertility  beyond  sixteen  months  already  exhibit  a  degTce 
of  relative  sterility. 

The  annual  summary  of  births,  deaths,  and  causes  of  death  in  England 
and  Wales,  and  in  London  and  other  large  towns,  for  the  year  1906  shows  that 
the  marriages  in  England  and  Wales  during  the  year  1906  numbered  269,734, 
corresponding  to  a  rate  of  15.6  persons  married  per  1,000  of  the  population  at 
all  ages.  This  rate  was  0.3  per  1,000  above  the  corresponding  rate  in  1905, 
but  was  0.2  per  1,000  below  the  average  rate  in  the  ten  years  between  1896- 
1905.  The  births  registered  in  1906  numbered  934,391,  and  were  in  propor- 
tion of  27.0  per  1,000  of  the  population  at  all  ages;  this  rate  was  0.2  per  1,000 
below  the  rate  in  1905,  and  lower  than  the  rate  in  any  other  year  in  record ; 
compared  with  the  average  in  the  ten  years  1896—1905  the  birth  rate  in  1906 
showed  a  decrease  of  1.7  per  1,000.  The  deaths  registered  in  1906  numbered 
530,715,  and  were  in  the  proportion  of  15.4  per  1,000  of  the  population;  this 
rate  was  0,2  per  1,000  above  the  rate  in  1905.  Compared  with  the  average 
in  the  ten  years  1896—1905  the  death  rate  in  1906  showed  a  decrease  of  1.4 
per  1,000.     (London  Times ^  June,  1907.) 

The  table  below  shows  the  calculated  amounts  of  sterility  at  different 
periods  of  married  life  in  women  married  at  different  ages,  the  table  being 
calculated  for  twentv  months. 


NATIONAL    IMPORTANCE. 


349 


Showing  the  Relative  Sterility  of  a  Mass  of  Wives  Married  at  Different  Ages  at  Suc- 
ceeding Epochs  in  Married  Life. 


Age  of  Mother  at  Marriage. 


Proportion  sterile  about  the  5th  year  of 

married  life  is  about  1  in 

Or  a  percentage  of 

Proportion  sterile  about  the  10th  year 

of  married  life  is  about  1  in 

Or  a  percentage  of 

Proportion  sterile  about  the  15th  year 

of  married  life  is  about  1  in 

Or  a  percentage  of 

Proportion  sterile  about  the  20th  year 

of  married  life  is  about  1  in 

Or  a  percentage  of 

Proportion  sterile  about  the  25th  year 

of  married  life  is  about  1  in. 

Or  a  percentage  of 


15-19. 

20-24. 

25-29. 

30-34. 

35-39. 

2.78 
35.9 

2.61 
38.3 

1.68 
59.4 

1.51 
66.0 

1.19 
84.1 

2.09 
47.9 

1.71 
58.3 

1.39 
71.8 

1.24 
80.8 

1.57 
63.8 

1.32 
75.5 

1.10 
90.9 

1.05 

95.5 

1.24 

80.4 

1.02 
97.6 

1.13 

88.6 

1.00 
99.65 

1.01 

98.7 

Total. 


2.09 
47.9 

1.61 
62.1 

1.26 

79.2 

1.11 

89.8 

1.01 
99.03 


Showing  the  Variations  of  Sterility  According  to  the  Ages  of  the  Wives. 


Ages  op  Wives  at 
Marriage. 

15-19. 

20-24. 

25-29. 

30-34. 

35-39. 

40-44. 

45-49. 

50,  etc. 

Total. 

Number  of  wives. .  . 

700 

1,835 

1,120 

402 

205 

110 

46 

29 

4,447 

First  children 

649 

1,905 

809 

251 

96 

10 

2 

3,722 

Sterile  wives 

51 

311 

151 

109 

100 

44 

29 

725 

Percentage  sterile.  . 

7.3 

27.7 

37.5 

53.2 

90.9 

95.6 

100 

16.3 

Proportion  sterile,  1 

m 

13.72 

3.60 

2.66 

1.88 

1.10 

1.05 

100 

6.13 

The  main  element,  says  Duncan,  in  expectation  of  sterility  is  the  age  at 
marriage,  but  statistics  suggest  other  laws,  namely,  that  the  question  of  a 
woman's  being  probably  sterile  is  decided  in  three  years  of  married  life,  only 
seven  per  cent  bearing  after  this  period. 

Another  law  is  that  when  the  expectation  of  fertility  is  greatest  the  question 
of  probable  sterility  is  soonest  decided  and  vice  versa,  for  it  has  been  noted 
that  of  wives  married  from  twenty  to  twenty-four  who  are  all  fertile,  only  six 
and  two-tenths  per  cent  began  to  bear  after  three  years  of  marriage. 

Also,  in  writing  of  age,  he  says  that  "  although  it  seems  absurd  to  rank 
marriage  among  the  causes'  of  sterility,  yet  the  conclusion  that  it  is  so,  at  least 
in  the  very  young,  appears  to  be  inevitable." 

Showing  the  Initial  Fecundity  of  Women  under  Twenty  Years  op  Age  Within  the 

First  Two  Years  of  Marriage. 


Ages  op  Wives  Newly  Married. 

16. 

17. 

18. 

19." 

Number  of  wives  newly  married 

43 
4 

10.7 

7.7 

12.90 

108 

27 
4.0 
3.3 

30.00 

225 

98 
2.3 
2.1 

46.44 

314 

Number  of  wives  mothers  within  two  years  of  marriage 
Proportion  of  latter  to  former  is  1  in           

177 
1.8 

Proportion  after  correction  for  immaturity  is  1  in ...  . 
Or  percentage                                  

1.7 

57.84 

350 


STERILITY. 


So  that  the  Legislature,  by  raising  or  depressing  tlie  majority  age,  might 
exercise  control  over  the  population.  In  England  about  nine  thousand  young 
persons  of  the  age  of  twenty  and  under  twenty-one  marry  annually,  and  one 
hundred  and  thirty-nine  thousand  at  twenty-one  to  twenty-five. 

Another  test  of  sterility  given  by  this  author  is:  How^  soon  after  marriage 
does  a  woman  bear  her  first  child  ?  Some  statisticians  give  eleven  and  a  half 
months,  but  Ansell,  quoted  by  Duncan  as  the  most  accurate  authority,  gives 
data  of  six  thousand  and  thirty-five  cases,  showing  a  mean  interval  of  sixteen 
months. 

Showing  the  Intekval,  Between  Marriage  and  the  Birth  op  First  Children. 


Year 

AFTEH    MaKRIAGE. 

Number  of  First  Children. 

Year  after  Marriage. 

Number  of  First  Children. 

1 
2 
3 

3,159 

2,163 

421 

8 

9 

10 

11 

7 
7 

4 

137 

11 

o 

5 

69 

12 

4 

6 

26 

13 

3 

7 

21 

14 

2 

Total. 


6,035 


And  the  annexed  table  also  shows  there  is  no  good  presumption  of  sterility  till 
the  fourth  vear  of  married  life  is  entered  on. 


DEVELOPMENT    OF    KNOWLEDGE. 

The  history  of  the  recognition  and  treatment  of  sterilitj^  is  fraught  with 
interest  no  whit  behind  that  of  many  other  branches  of  medicine  and  surgery 
wdiich  have  undergone  such  remarkable  evolution  within  the  past  two  or  three 
decades. 

Until  recently  the  conception  which  prevailed  was  that  there  was  but  one 
form — ^that  w^hich  was  evidently  commonest  in  Biblical  days,  when  w^e  read 
in  the  inspired  record  of  the  sterile  women  that  ''  The  Lord  had  closed  up  all 
wombs"  (Gen.  xx.  18),  and  of  the  relief  of  such  condition,  "■  God  opened  her 
womb"  (Gen.  xxx.  22).  With  the  increasing  '^  civilization  "  of  the  world  a 
number  of  new  causes  have  become  operative  which  were  overlooked  until 
recent  times.  Even  so  short  a  time  ago  as  the  days  of  Marion  Sims,  closure  of 
the  womb  w^as  practically  the  only  condition  recognized  and  all  cases  were  sub- 
jected to  the  same  treatment — dilatation.  At  this  period — the  sixties  and  seven- 
ties of  the  last  century — the  w^ife  was  always  treated,  the  treatment  being 
always  one  and  the  same  thing. 

I^oeggerath  ("Die  latente  Gonorrhoea  im  weiblichen  Geschlecht."  Bonn, 
1872),  neglected  and  ridiculed  like  most  pioneers  who  essay  to  overthrow  settled 
convictions,  was  the  apostle  of  the  new  doctrine  which  rightly  threw  the  re- 
sponsibility for  the  common  sterility  upon  the  uncured  and  often  incurable 
gonorrheas  transferred  from  the  courtesan  to  the  wife,  from  the  bawdy  house 


ETIOLOGY    OF    STEKILITY    IN    THE    MALE.  351 

to  the  marriage  bed.  Slowly,  very  slowly,  aided  by  the  powerful  pen  of  Max 
Sanger  of  Germany  (Verhand.  d.  Deutsch  Gesell.  f.  Gyn.  u.  Geh.  Miinchen, 
18S6)  did  the  views  of  JSToeggerath  become  the  conviction  of  the  medical  pro- 
fession at  large. 

Following  the  discovery,  of  this  writer,  wrought  out  of  his  remarkable  in- 
sight and  analysis  of  his  chemical  findings,  the  extraordinary  discovery  of  the 
gonococcus  by  N^eisser  placed  the  question  of  the  diagnosis  of  catarrhal  and 
gleety  discharges  in  both  sexes  beyond  a  peradventure  and  hastened  the  recep- 
tion of  ISTeisser's  discovery  by  putting  incontestable  evidence  into  the  hands  of 
the  profession.  Had  it  not  been  for  the  work  of  ISTeisser,  Bumm,  Wertheim, 
and  others,  I  suppose  this  important  question  would  still  be  under  discussion 
and  the  wife  still  receiving,  as  she  readily  accepts,  all  the  blame  for  the  often 
distressing  situation. 

We  note  in  the  history  of  this  interesting  subject  the  following  illuminating 
facts : 

(1)  The  age-long  recognition  of  the  fact  that  sterility  may  be  due  to  closure 
of  the  neck  of  the  womb. 

(2)  The  discovery  of  the  importance  of  gonorrhea,  especially  in  its  latent 
forms,  and  particularly  in  the  male. 

(3)  The  discovery  of  the  gonococcus  giving  scientific  precision  and  cer- 
tainty to  the  views  of  ISToeggerath. 

(4)  Greater  skill  in  examining  the  internal  genitalia  in  woman  revealing 
tubal,  ovarian,  and  pelvic  inflammatory  diseases  often  responsible  for  sterility 
and  hitherto  unsuspected. 

It  would  be  gratifying  to  add  that  pari  passu  with  the  discovery  of  these 
new  causes  have  gone  the  therapeutics  of  the  condition.  Unfortunately,  as  is 
too  often  the  case,  therapy  lingers  with  laggard  feet  outside  the  doors  of  etiology. 

Although  it  is  here  my  professed  aim  to  deal  with  medical  gynecology 
alone,  I  cannot  discuss  this  important  subject  without  giving  at  least  brifef  con- 
sideration to  the  question  of  male  sterility. 

It  is  crudely  supposed  and  is  everywhere  accepted  by  the  laity  that  ability 
to  complete  the  sexual  act  is  of  itself  siifficient  proof  that  the  husband  is  capable 
of  begetting  offspring  and  the  responsibility  for  sterility  does  not  rest  on  his 
shoulders,  that  is  to  say  in  more  delicate  and  technical  terms  that  potentia 
coeundi  is  equivalent  to  potentia  generandil 

ETIOLOGY    IN    THE    MALE. 

There  are  two  kinds  of  incapacity  for  ]3rocreation  on  the  part  of  the  male 
which  entail  sterility  in  the  wife. 

(a)   Inability  to  enter  upon  or  complete  the  sexual  relation. 

(6)  Where  the  relation  is  apparently  in  every  respect  normal,  the  seminal 
fluid  is  partly  or  wholly  devitalized,  containing  few  or  no  living  well-developed 
spermatozoa. 


352  STEKILITT. 

Sterility  of  the  first  kind  in  the  male  may  arise  from  marked  congenital 
deformities  such  as  epispadias  and  hypospadias,  exstrophy  and 
cryptorchism. 

It  may  also  be  due  to  extreme  self-abuse  in  youth  and  the  exhaustion  of  the 
sexual  ]30wers  by  early  excessive  venery.  I  have  seen  one  instance  of  a  man 
postponing  marriage  until  the  sixties  and  then  selecting  a  beautiful  young  wife 
rather  that  she  might  preside  over  his  house  than  for  love  he  bore  her:  he  had 
no  sex  desire  and,  held  in  check  by  his  indifferent  wife,  was  unable  to  consum- 
mate the  marriage  relation. 

All  the  conditions  of  male  sterility  belonging  to  this  category  are  at  once 
manifest,  being  allied  to  an  impotence  which  is  almost  invariably  a  source  of 
acute  distress  and  shame  to  the  victim,  who  for  this  reason  rarely  ventures  to 
enter  on  the  married  state. 

Such  conditions  are  not  affected  by  treatment,  least  of  all  by  any  of  the 
wretched  quack  devices  by  which  the  victims  are  deluded  from  year  to  year  to 
the  depletion  of  their  purses,  but  without  quenching  the  spark  of  hope  which 
renders  them  susceptible  to  the  next  lying  advertisement  of  the  lowest  parasites 
prostituting  the  name  of  doctor.  I  would  single  out  particularly  the  disgusting 
exhaustion  ajDparatus  employed  to  delude  the  poor  victim  by  inducing  a  transient 
semblance  of  vitality.  Under  such  circumstances  the  thoughts  of  the  patient 
are  best  diverted  into  happier  channels,  and  if  unmarried,  let  the  assurance  be 
given  that  life  holds  within  its  compass  a  promise  of  nobler  things  than  that 
of  permitting  the  brain  to  revolve  around  the  genital  organs  as  the  centre  of 
interest. 

The  second  group  comprises  males  affected  with  gonorrhea,  the  de- 
structive effects  of  which  are  seen  in  the  epididymis,  the  vas  deferens,  the 
seminal  vesicles,  and  the  prostate  gland.  If  through  this  cause  both  testicles 
are  rendered  functionless,  or  both  vasa  deferentia  closed  by  an  epididymitis 
or  a  deferinitis  the  result  will  be  an  azoospermia  or  a  fluid  in  which 
there  will  be  no  living  spermatozoa.  A  chronic  vesiculitis  or  a  chronic 
prostatitis  will  develop  an  oligospermia  in  which  the  living  elements 
are  few  and  far  between  or  in  which  they  are  altogether  absent,  though  dead 
ones  or  only  those  with  feeble  motile  powers  may  be  found — ^necrospermia. 

These  affections  render  the  male  incapable  of  generating  offspring  (im- 
potentia  generandi),  though  capable  of  an  apparently  normal  sexual  relation 
(potentia  coeundi). 

A  vesiculitis  can  be  discovered  by  a  rectal  examination  which  reveals 
tenderness  and  fibrous  thickening  about  the  seminal  vesicles.  Pressure  on  these 
organs — "  milking "  them — will  often  induce  a  discharge  into  the  urethra 
which  can  be  examined  at  once.  In  the  same  way  the  prostatic  secretion  can 
be  secured  and  examined.  Casper  (Monatsh.  f.  Urolog.,  1900,  vol.  5,  p.  385) 
found  prostatitis  in  eighty-five  per  cent  of  cases  of  chronic  urethritis; 
that  is,  in  a  gTOup  in  which  the  disease  had  persisted  over  two  months. 

Out  of  two  hundred  and  fortv-two  cases  of  double    epididymitis    col- 


ETIOLOGY    IN    THE    MALE.  353 

lected  by  Finger,  this  eminent  authority  found  two  hundred  and  seven  cases 
of  azoospermia,  while  Kehrer  ("  Beitrage  zur  klinischen  und  experimen- 
tellen  Geburtskunde  und  Gynakologie,"  1892,  p.  76)  found  an  azoospermia 
in  tliirty  and  twenty-one  hundredths  per  cent  of  ninety-six  sterile  marriages. 
Sanger,  in  analyzing  110  such  marriages,  found: 


in  53.6  p.  c.  normal  sperm, 
"    11.8      "     oligospermia, 
"    33.6      "     azoospermia. 


These  data  are  sufficient  to  show  the  extreme  importance  of  investigating 
the  male  in  every  case  of  sterility,  and  the  determination  of  male  sterility  is 
easy  if  the  microscope  is  used.  It  should  be  borne  in  mind  that  it  is  not  enough 
to  rely  upon  the  general  assurance  of  the  man,  and  least  of  all  upon  that  of 
the  wife,  that  he  "  is  all  right." 

The  sperm  is  best  secured  for  examination  after  a  coitus  condomatus,  or  by 
the  act  of  withdrawal  and  the  discharge  of  some  of  the  semen  into  a  small 
bottle  which  is  corked  and  at  once  dropped  into  a  bottle  of  warm  water  jacketed 
with  flannel,  which  should  be  kept  warm,  not  hot,  until  examined  microscop- 
ically. In  view  of  such  examinations  the  husband  should  remain  continent  for 
four  or  five  days,  and  will  do  best  to  break  his  abstinence  in  the  early  morning. 

The  physician  must  never  forget  that  even  though  repeated  examinations 
show  azoospermia,  at  a  later  date  a  few  living  cells  may  be  found  and 
conception  be  possible.  Such  are  some  of  the  cases  in  which  pregnancy  occurs 
after  years  of  sterile  married  life. 

When,  as  the  result  of  his  analysis  of  the  two  factors  involved  in  every  case 
of  sterility,  the  physician  finds  that  the  trouble  lies  at  the  husband's  door  it  is 
his  duty  either  to  say  nothing  or  to  lay  the  blame  where  it  belongs.  But  in  no 
instance  should  the  wife  be  allowed  to  suffer  continual  mental  disquietude  or  be 
subjected  to  unnecessary  treatments  for  an  ailment  which  is  not  primarily  hers. 
The  fellow  feeling  which  sometimes  induces  the  physician  to  gloss  over  the 
husband's  defect  and  lay  an  unmerited  burden  of  worry  and  sorrow  on  the 
shoulders  of  the  innocent  wife  is  not  creditable  to  our  profession. 

The  hope  of  procreation  is  apparently  forbidden  by  the  conditions  of  azoo- 
spermia, but  the  cautious  physician  will  always  carefully  avoid,  for  two 
reasons,  giving  a  hopeless  prognosis.  First,  the  event  may  disappoint  his 
expectations  by  the  temporary  nature  of  the  condition  in  some  cases.  Every 
man  with  a  large  experience  can  recall  cases  where  conception  has  occurred 
after  ten,  twelve,  or  even  more  years  of  sterility.  Second,  the  effect  on  the 
man  thus  condemned  may  make  him  morbid  or  melancholic. 

In  regard  to  the  proportion  of  cases  in  which  the  husband  is  responsible  for 

the  sterility,  I  give  some  statistics  taken  from  the  excellent  work  of  F.  Schenk 

("  Die   Pathologic   und    Therapie    der   Unfruchtbarkeit   des    Weibes,"    p.    90 

et  seq.). 

24 


354  STEEILITT. 

'•  Lier  and  Aselicr,  who  examined  the  s-tatistics  of  primary  sterility,  that  is 
to  say  of  women  who  had  never  conceived,  found  in  227  cases  in  Prochownik's 
clinic,  that  76  sought  advice  on  account  of  sterility,  151  on  account  of  various 
gynecological  affections.  The  husbands  of  these  women  were  examined  in  132 
cases,  and  it  was  found  that  42,  or  31.8  per  cent,  had  no  living  sperm  cell 
(azoospermia),  while  11,  or  8.3  per  cent,  were  impotent;  41  of  the  men  had 
infected  their  wives  with  gonorrhea,  and  only  38,  28.8  per  cent,  were  healthy. 
According  to  these  figures  the  fault  lay  on  the  side  of  the  man  in  71.2  per  cent 
of  the  eases.  In  39  cases  where  the  husband  was  examined,  or  29.5  per  cent, 
there  was  a  definite  obstacle  to  conception  on  the  part  of  the  woman.  There 
were  50  men  who  refused  examination,  and  27  of  these  had  infected  their  wives 
with  gonorrhea;  45  men  could  not  be  examined,  for  various  reasons,  and  in 
this  gToup  13  wives  were  found  to  have  gonorrhea.   ... 

^^  In  197  cases  of  acquired  sterility  examined  by  Lier  and  Ascher,  the  causes 
of  it  were  found  to  be  distributed  as  follows : 

Coitus  reservatus 48  cases 

Azoospermia 2      " 

Gonorrheal  infection 35       " 

Puerperal  infection 27      " 

Various  genital  affections 85       " 

"  In  this  group,  leaving  out  of  consideration  cases  of  facultative  (volun- 
tary) sterility,  the  fault  lay  with  the  man  in  18.8  per  cent  of  the  whole.   .  .  . 

"  Sanger  investigated  material  covering  the  period  between  1891  and  1899, 
and  found  397  cases  of  primary  sterility  and  21  cases  of  secpndary  sterility. 

"•  I.  Of  these  397  sterile  marriages  both  man  and  wife  were  examined  in 
110  cases.  The  examination  of  tlie  semen  showed  normal  sperm  cells  in  59 
cases.  In  13  cases  there  was  deficiency  of  semen  (oligospermia),  in  37  there 
was  azoospermia,  and  in  1  case  impotentia  coeiindi.  Taking  these  statistics  just 
as  they  stand  we  find  a  percentage  of  46.4  in  which  the  sterility  was  on  the  male 
side.  Of  the  59  men  with  normal  sperm  cells,  there  were  28  who  had  certainly 
had  gonorrhea,  and  of  this  number  the  wives  were  infected  in  14  cases,  making 
the  total  proportion  of  male  sterility  in  these  110  cases  65,  or  59.1  per  cent. 
Only  45  marriages  could  be  found  in  which  no  blame  could  be  attached  to  the 
husband.   .   .  . 

"  If  these  110  cases  are  analyzed  and  the  proportion  of  causes  of  sterility 
stated  in  percentages,  the  results  are  as  follows: 

"  (a)   Direct  sterility  due  to  the  man  by  reason  of  impotence, 

azoospermia,  or  oligospermia,  51  cases 46.4  per  cent 

Indirect  sterility  due  to  the  man  through  the  transmission 

of  gonorrhea  to  his  wife,  14  cases 12.7         " 

Total  of  male  sterility 59.1  per  cent 


ETIOLOGY    IN    THE    MALE.  355 


"  (6)   Sterility  in  the  woman  caused  by 

Endometritis  fimgosa 6  cases 

Parametritis  post,  atr 5 

Stenosis  of  cervical  canal  and  ext.  os 16      "    — 14.5 

Anomalies  of  development 3 

Stenosis  with  endometritis 7 

Retroversion  and  retroflexion 4 

Ovarian  cyst 1  case 

Loss  of  semen 1 

JSTo  pathological  finding 2  cases 


Total  of  45  cases .  .  .' 40.9  per  cent 

"  These  statistics  approach  closely  to  those  of  Lier  and  Ascher,  which  made 
the  percentage  of  cases,  in  which  both  parties  were  examined  and  the  fault  lay 
with  the  husband,  71.2  per  cent.  Lier  and  Ascher  found  direct  sterility 
caused  by  azoospermia  and  impotence  in  40.1,  and  indirect  sterility, 
through  transmission  of  gonorrheal  infection,  in  31.1  per  cent  of  their  cases. 

"  II.  In  287  cases  of  primary  sterility  the  woman  only  was  examined,  with 
the  following  results : 

"  (a)  Gonorrheal  infection  was  found  in  107  cases,  or  34.8  per  cent.  In 
28  of  these  cases,  or  9.7  per  cent,  fresh  gonorrheal  infection  was  present,  in 
the  form  of  urethritis.  Bartholinitis,  endometritis,  etc.  In  79  women,  or  27.5 
per  cent,  there  were  inflamm.atory  changes  of  the  adnexa  such  as  pyosalpinx, 
salpingo-oophoritis,  and  chronic  peri-salpingo-oophoritis. 

"(h)  Besides  these  107  cases  in  which  the  woman  had  gonorrhea  with 
resulting  sterility  for  which  the  husband  was  responsible,  there  were  33  men 
with  gonorrhea  whose  wives  showed  no  evidence  of  it.  Of  this  number  16 
had  gonorrhea  without  involvement  of  the  testicle;  11  had  single  epididymitis 
with  the  gonorrhea ;  and  in  6  there  was  a  double  epididymitis.  As  the  semen 
of  these  men  Avas  not  examined,  it  cannot  be  said  with  certainty  whether 
the  sterility  was  due  to  gonorrhea  in  them  or  to  non-gonorrheal  disease  in 
the  wife.  The  various  affections  found  to  exist  in  these  33  women  were 
as  follows : 

"  Infantile  uterus 2  cases 

Stenosis  (uterus  parvus)   6      " 

Escape  of  semen 2      " 

Eungous  endometritis 8      " 

Simple  endometritis  (with  stenosis) 5      " 

Retroposition  of  uterus  (with  stenosis) 4      " 

Chronic  atrophic  parametritis 2 

Myomata  of  uterus •  1  case 

Adipositas 1 

Anemia 1 


356  STERILITY. 

"  (c)  Of  the  remaining  147  eases  in  wliicli  the  woman  only  was  examined 
no  gonorrheal  infection  was  found,  while  there  was  no  record  of  gonorrhea  in 
the  man,  either  through  examination  of  the  semen  or  admission  on  his  own  part. 
In  the  absence  of  any  examination  of  the  semen,  it  is  not  justifiable  to  charge 
the  sterility  to  the  wife,  even  though  she  is  found  to  have  a  definite  gyn- 
ecological afi^ection.     The  genital  affections  in  these  cases  are  as  follows: 

"  Inflammations  of  non-gonorrheal  origin. 

Tuberculosis  of  the  adnexa 1  case 

Fungous  endometritis 13  cases 

Parametritis,  atroph.  post 4      " 

cc  T^-    1  ,  18  cases 

JJisplacements. 

Retroflexion  and  retroversion  of  uterus 6  cases 

"  "  "  "       "     with  metritis 1  case 

"  "  "  "       "        "     stenosis  of  external  os.  .  .      9  cases 

"  Anomalies  of  development. 

Complete  stenosis  of  the  cervical  canal  and  of  the  external  orifice  of 

the  uterus,  due  to  anteflexion  of  a  small  uterus 28  cases 

Anteflexion  uteri  parvi  (without  stenosis) 4      " 

Stenosis  with  fungous  portio 1  case 

Atresia  and  stenosis  of  the  hymen 4  cases 

Fetal  uterus   1  case 

Infantile  uterus 7  cases 

Hypoplasia  of  the  uterus 1  case 

Atrophy  of  uterus  (climax  precox) 1  " 

In  addition  to  these : 

Stenosis  of  cervix  and  of  external  os  with  endometritis ■    26  cases 

"       "         "     "  "         "      "     parametritis    3      " 

u  i\.r      1  29  cases 

J\  eoptasms. 

Polyp  of  cervix   1  case 

Carcinoma  of  cervix 2  cases 

Ovarian  cystoma 4      " 

Myomata  of  uterus 9       " 

16  cases 
"  Constitutional  causes. 

Anemia  (chlorosis) 6  cases 

Adipositas 6      " 

Tuberculosis  of  lung 2      " 

14  cases 


ETIOLOGY    IN    THE    FEMALE.  357 

"  In  the  remaining  cases  where  the  pelvic  organs  were  normal  there  was 
vaginismus  in  2  cases;  intact  hymen  in  1  case;  loss  of  semen  in  1 
case;  while  in  three  cases  which  sought  advice  on  account  of  sterility  no 
hindrance    to    conception    whatever    could    be   found, 

"  III.  In  the  investigation  of  secondary  sterility  there  were  21  cases 
in  which  the  woman  only  was  examined,  and  in  these  the  causes  of  sterility  were 
as  follows : 

Gonorrhea  with  disease  of  adnexa. 6  cases 

"  without  disease  of  adnexa  (endometritis)  ...    3      " 

//   Tr->  11*  y    C8-SGS 

ruerperal  diseases. 

Pelvic  peritonitis 1  case 

Fungous  endometritis  with  parametritis 2  cases 

Parametritis  with  disease  of  the  adnexa 1  case 

"  (uncomplicated)   1  " 

5  cases 

"  The  percentage  of  puerperal  diseases  in  the  causation  of  secondary  sterility 
is  24  per  cent,  while  that  of  gonorrhea  is  43  per  cent." 


ETIOLOGY    IN    THE    FEMALE. 

Anatomical  and  Physiological  Causes. — Bearing  in  mind  that  certain  devia- 
tions from  the  normal  sometimes  cause  sterility,  it  becomes  important  to  con- 
sider first  the  anatomy  and  physiology  of  the  female  genital  organs. 


Stenosis 


Infected 
Barth  gl. 


Atresia  of  vag. 


"Fig.  96. — -Some  of  the  Causes  of  Sterility  Brought  Together  in  One  Diagram.  These  are:  An 
infection  of  Skene's  or  of  Bartholin's  gland  significant  of  gonorrhea;  atresia  of  the  vagina;  stenosis 
of  the  cervix;  a  polyp  hanging  into  the  uterine  cavity;  fibroid  tumors;  a  fibroid  at  the  attachment 
of  the  uterine  tube ;  a  parovarian  cyst  splinting  the  tube  and  separating  it  from  the  ovary ;  a  nodular 
salpingitis  due  to  gonorrheal  or  tubercular  inflammation;  an  atresia  of  the  tube,  of  inflammatory 
origin;  ovarian  and  tubal  adhesions. 


358 


STERILITY. 


The  various  conditions  likely  to  be  found  associated  with  sterility,  when 
any  demonstrable  lesion  exists,  are  shown  for  the  sake  of  clearness  and  appeal 
to  the  eye  in  Figure  96,  These  may  be  traced  categorically,  step  by  step,  from 
the  vaginal  orifice  upwards : 

A  gonorrheal  infection  of  Skene's  glands. 

An  infection  of  Bartholin's  (vulvo-vaginal)  gland. 

A  stricture  of  the  vagina. 

A  narrow  cervix. 

A  uterine  polyp. 

A  uterine  fibroid  tumor,  either  in  the  wall  or  blocking  a  tube. 

A  parovarian  cyst. 

A  nodular  salpingitis,  from  gonorrhea  or  tuberculosis. 

An  atresia  of  the  uterine  tube  from  inflammation. 

Ovarian  adhesions. 

The  vulva  is  significant  only  in  so  far  as  a  small  mons  with  small  labia 
and  a  slight  capillary  development  such  as  one  sees  in  children  approaching 
their  teens,  should  at  once  put  the  physician  on  his  guard,  as  this  condition  may 
indicate  a  similar  want  of  development  of  internal  organs. 


Fig.  97. — Cyst  of  the  Left  Bartholin's  Gland,  often  an  Indication  of  a  Gonorrheal  Infection 

AND  THE  Cause  of  Sterility. 


ETIOLOGY    IN    THE    FEMALE.  359 

Three  things  must  be  carefully  noted  in  examination  of  the  vulva  in  its 
deej)er  portion  where  the  vulvo-vaginal  (Bartholin's)  glands  lie  buried  close 
to  the  entrance  into  the  vagina  and  posteriorly.  Each  of  these  notable  marks 
suggests  the  existence  of  a  chronic  gonorrheal  affection. 

( 1 )  The  gland  itself  may  feel  like  a  little  dense  sclerotic  mass  the  size  of  a 
small  bean  (see  Fig.  97),  the  residuum  of  an  old  gonorrheal  affection  called  by 
Sanger  adenitis  glandulce  Bartholince  scleroticans. 

(2)  The  duct  of  the  gland  may  feel  like  a  little  dense  cord. 

(3)  The  outlet  of  the  gland  where  it  discharges  above  at  the  vulvo-vaginal 
orifice  near  the  hymen  may  appear  intensely  red ;  it  is  often  likened  to  a  flea- 
bite,  and  has  been  called  the  macula  gonorrhceica.  Caution,  however,  must  be 
used  in  drawing  an  inference  from  the  macula  alone.  It  is,  in  my  experience, 
not  a  safe  guide.  If  the  gland  or  its  duct  is  diseased,  careful  squeezing  may 
cause  a  little  pus  to  exude  which  should  be  transferred  to  a  cover  slip  and  exam- 
ined microscopically. 

The  Hymen. — A  rigid  or  unruptured  hymen  shows  that  coitus 
has  never  been  completed,  if  attempted.  The  signs  of  a  defloration,  whether 
accomplished  digitally,  instrumentally,  or  sexually,  are  always  evident  in  the 
hymen.  The  most  important  sign  is  to  be  noted  in  its  elasticity,  which  easily 
admits  one  or  two  fingers  into  the  vagina  without  distress.  If  the  well-oiled 
finger  can  be  readily  introduced  into  the  vagina  without  eliciting  a  cry,  a  con- 
clusion may  be  drawn  that  some  penetrating  body  has  entered  the  same  channel. 
A  single  digital  examination  is  thus  sufficient  to  destroy  the  signs  of  virginity. 
Too  often  the  occasion  for  such  unnecessary  rupture  lies  in  the  examination 
of  a  young  girl  who  simply  begins  to  complain  of  a  dysmenorrhea.  Repeated 
unskilled  examinations  and  treatments  of  young  persons  effect  nothing '  for 
their  cure  and  constitute  a  crime  closely  allied  to  rape.  More  than  two  cen- 
turies ago  Severinus  Pinseus  uttered  the  sound  dictum,  "  Magnum  est  crimen 
perrumpere  virginis  hymen."  Let  it  be  inscribed  over  the  door  of  every  con- 
sulting room. 

On  or  about  the  hymen  one  often  finds  tender  red  spots,  carefully 
described  by  Sanger ;  these  are  frequently  the  outcome  of  a  chronic  gonorrhea. 

The  Urethra. — The  urethra  may  appear  swollen  and  red,  bleeding  to 
the  touch  and  constituting  a  source  of  much  distress,  causing  the  patient  to 
shrink  from  examination.     This,  too,  is  often  due  to  gonorrhea. 

Skene's  Glands. — Often  the  seat  of  a  chronic  gonorrheal  infection  is 
found  in  Skene's  glands  (glandulse  paraurethrales)  manifested  by  a  puffi- 
ness  and  eversion  of  the  lips  of  the  urethra,  exposing  one  or  both  of  the 
glandular  orifices  which  normally  lie  concealed  just  within  the  external 
meatus.  On  squeezing  the  glands  by  pressing  up  under  the  urethra  and  milk- 
ing them  outwards  with  the  finger  tip  a  drop  of  pus  may  be  forced  out  of  one 
or  both  sides.  If  Skene's  glands  are  empty,  then  it  is  well  to  dry  the  urethral 
orifice  and  to  stroke  the  entire  urethra  dovmwards  from  the  neck  of  the  blad- 
der to  the  meatus  externus,  taking  up  any  discharge  thus  brought  to  light 


3Q0  STERILITY. 

for  furtlier  examination.     A  gonorrheal  infection  tlnis  discovered  ^vill  be  evi- 
dence of  a  chronic  urethritis. 

It  should  be  borne  in  mind  that  a  careful  distinction  must  be  made  between 
a  milky  discharge  often  seen  and  due  to  an  accumulation  of  epithelial  debris 
within  the  glands  and  a  purulent  discharge.  The  microscope  only  is  competent 
to  decide. 

In  its  chronic   form    a   urethritis   occasionally    (in  women  rarely)    results 
in    a    stricture    of    the    urethra.      This    is    readily    found    by    attempting  _ 
to  pass  an  ordinary  urethral  catheter.     A  large  experience  justifies  the  state- 
ment that  I  have  hardly  seen  more  than  six  cases  of  strictural  urethra  in 
women. 

The  Y  a  gin  a. — Two  deformities  in  the  vagina  call  for  notice:  fi.rst  a 
double  or  septate  vagina  in  which  the  canal  is  divided  up  to  the  cervix 
which  presents  two  openings  (or a),  one  in  each  half.  This  is  a  condition 
of  arrested  development  in  Avhicli  the  uterus  may  also  be  septate  or  two-horned, 
or  in  which  while  one-half  of  the  uterus  is  developed  the  opposite  half  may 
remain  rudimentary.  Startling  as  this  condition  appears  at  first  sight  it  does 
not  cause  infertility ;  the  real  danger  lies  in  the  possibility  of  a  conception 
tahine;  place  in  the  rudimentary  side  followed  by  early  rupture,  or  in  late 
rupture  of  the  more  developed  side. 

Second,  there  may  be  stricture  of  the  vagina,  either  congenital  or 
acquired.  In  both  cases  the  vagina  ends  in  a  cul-de-sac,  but  in  the  congenital 
form  the  uterus  above  is  undeveloped;  in  the  acquired  the  uterus  is  not 
affected.  It  must  be  borne  in  mind  that  many  of  the  cases  formerly  labelled 
congenital  atresia  were  in  reality  atresias  due  to  sloughing  of  the  vagina  occur- 
ring in  the  course  of  a  scarlatina,  a  severe  typhoid  fever,  or  some  other  infec- 
tious disease  in  childhood. 

An  atresia  may  follow  the  sloughing  incident  to  a  difficult  lal)(»r  inducing 
a  one-child  sterility.  An  atresia  well  within  the  introitus  may  not  be  dis- 
covered until  the  medical  examination  is  made,  as  the  shortened  vagina  may 
lengthen  from  intercourse. 

A  reddened,  inflamed,  patchy,  or  granular  vagina,  with  a  milky  secretion 
(colpitis  maculosa  or  granulosa),  is  often  evidence  of  an  old  gonor- 
rhea. The  excessive  acidity  of  the  vaginal  secretion,  which  frequently  exco- 
riates the  vulva  and  the  adjacent  skin,  may  also  serve  to  destroy  the  sperma- 
tozoa. The  reaction  of  the  vaginal  secretion  must  always  be  tested  with  blue 
litmus  paper. 

Another  cause  of  sterility  is  shortness  of  the  vagina,  or,  in  the 
acquired  form,  a  broken-down  vaginal  outlet  which  refuses  to  retain 
the  spermatozoa.  Patients  often  complain  of  the  latter  condition,  namely,  the 
escape  of  the  seminal  fluid,  which  is,  to  them,  a  seemingly  self-evident  cause 
of  their  condition,  but  it  is  doubtful  how  far  it  is  really  instrumental  in  it. 
I  am  not,  myself,  disposed  to  assign  any  great  importance  to  it  in  the  causation 
of  sterility. 


ETIOLOGY    IN    THE    FEMALE.  361 

Affections  of  the  ISTeck  of  tlie  Uterus. — Between  the  vagina  and 
the  cervix  there  is  a  great  change  in  anatomical  conditions.  The  vault  or 
laquear  vagina?,  where  an  abundance  of  semen  is  deposited,  is  exchanged  for 
a  narrow  cervical  canal,  entered  by  a  constricted  orifice  and  leading  up  into  a 
flat  channel,  also  rigid,  out  through  the  uterine  tubes  and  through  the  star- 
shaped  channel  of  the  isthmial  portion  of  the  tubes  into  the  labyrinth  of  folds 
in  the  tubal  ampullae  where  the  spermatozoa  normally  meet  the  ovum.  Con- 
sidering the  complexity  of  the  arrangement,  the  wonder  is  that  the  conjunction 
between  the  sj)erm  cell  and  the  ovum  is  ever  effected.  The  progress  of  the 
spermatozoa  may  be  hindered  by  various  abnormal  conditions,  which  are  here 
considered  in  order. 

Elongation  of  the  Cervix  (col  tapiroides). — An  elongate  cervix 
lying  in  the  axis  of  the  vagina  and  projecting  down  toward  the  outlet  may 
present  an  obstacle  to  the  passage  of  the  semen.  This  condition  is,  as  a  rule, 
associated  with  a  sharp  anteflexion  of  the  uterine  body,  and  its  importance 
lies,  not  so  much,  perhaps,  in  the  length  of  the  cervix  or  in  the  flexion,  as  in 
the  maldevelopment  to  which  both  conditions  are  due. 

Smallness  of  the  Cervical  Orifice. — A  diminutive  opening  of  the 
cervix  into  the  vagina  is  the  only  cause  of  sterility  commonly  recognized  by  the 
laity  as  well  as  by  the  general  practitioner.  When  the  orifice  is  minute  (pin- 
hole size)  and  no  other  probable  cause  can  be  found  on  careful  examination, 
the  condition  is  worth  consideration  as  likely  to  be  an  efficient  barrier  to  the 
entrance  of  the  spermatozoa. 

Diseases  of  the  Uterus.- — Erosion  of  the  cervix  is  characterized  by  an 
enlarged  and  puffy  condition  of  the  os,  which  lies  in  the  centre  of  a  reddened 
area  presenting  a  granulated  appearance.  Such  a  condition  may  be  due  to 
hyperemia  and  swelling  of  the  mucosa  of  the  cervix,  which  having  no  other 
situation  in  which  it  can  expand,  rolls  out  at  the  cervical  os  and  so  becomes 
apparent  at  the  vagina.  In  other  cases  the  erosion  is  clearly  a  physiological 
extension  of  the  cervical  mucosa  into  the  vaginal  portion  of  the  cervix.  This 
is  the  innocent  affection  so  often  and  so  persistently  treated  under  the  name 
of  "  ulcers  of  the  womb,"  a  condition  which,  in  reality,  almost  never  exists. 

Infections  of  the  Cervix,  Gonorrheal  and  Otherwise,  Includ- 
ing Endocervicitis  and  Cervicitis. — A  simple  erosion  of  the  cervix 
must  not  be  mistaken  for  a  gonorrheal  infection  of  the  cervical  glands,  which 
in  some  respects  it  resembles.  A  gonorrheal  cervicitis  or  endocervicitis  is  char- 
acterized in  the  first  place  by  a  tenacious  mucoid  or  muco-purulent  discharge. 
This  ropy  discharge,  so  often  seen  in  women,  comes  invariably  from  one  source, 
and  that  is  the  glands  opening  onto  the  cervical  canal.  There  is  often  a  marked 
congestion  and  puffiness  of  the  cervix,  which  bleeds  easily  on  touch,  and  is 
inclined  to  bleed  copiously  when  caught  with  tenaculum  forceps.  Sometimes 
there  is  a  marked  eversion  of  the  cervical  mucosa  which  allows  the  secretion 
to  be  seen  issuing  from  the  glandular  orifice.  This  form  of  infection  is  deep- 
seated  and  obstinate  in  character,  persisting  for  years,  and  sometimes  until 


362 


STERILITY. 


the  natural  atrophy  of  the  parts  brings  relief.      The  cervical  glands  are  par 
excellence  the  seat  of  a  chronic  gonorrhea. 

Laceration  of  the  Cervix. — Cervical  laceration  is  sometimes  a  cause 
of  one-child  sterility;  but  a  word  of  caution  is  necessary  here  against  over- 
estimating the  importance  of  the  condition  from  this  point  of  view.  Laceration 
of  the  cervix  has  been  the  bug-bear  of  the  medical  profession  for  about  a  gen- 
eration, and  it  is  now  time  it  was  laid  in  its  grave.  A  simple  laceration,  by 
which  the  cervical  os  is  converted  into  a  slit,  or  else  the  cervix  forms  two 
distinct  lips,  more  or  less  deeply  notched  on  either  side,  must  be  regarded  as 
physiological,  and  calls  for  no  surgical  interference  whatever.  How  many 
women  in  whom  this  condition  existed  have  been  the  victims  of  the  meddle- 
some surgery  of  the  past !  Even  a  deep  laceration,  converting  the  cervix  into 
two  well-defined  flaps,  has  no  bad  effect  upon  the  general  health,  though  I  am 
not  prepared  to  deny  that  it  may  not  act  as  a  factor  in  the  production  of 
sterility.  The  serious  cervical  lacerations  are  those  in  Avhich  there  is  an  infec- 
tion of  the  cervical  glands  with  hyperemia,  infiltration,  and  eversion,  super- 
added to  the  laceration.  Such  cases  of  infected  cervices  undoubtedly  operate 
to  maintain  sterility,  both  by  the  infiltration  which  they  induce  and  by  the 
tough  secretion  arising  from  them  which  plugs  the  cervical  canal. 

Cancer  of  the  Cervix. — Cervical  carcinoma  is  a  disease  usually  asso-. 
ciated  with  an  acquired  sterility.  The  patient  who  has  a  cancer  of  the  cervix 
has  usually  borne  children,  but  ceases  to  conceive  when  the  cancer  appears. 
The  affection  has  no  practical  bearing  on  the  subject  in  hand  further  than 

exists  in  the  fact  that  the 
sterile  woman  is  compar- 
atively immune  from  this 
dreadful  malady. 

Cervical  Polyp. — A 
polyp  of  the  cervix  also  may 
prevent  conception.  These 
little,  soft,  mucoid  tumors 
are  usually  rose-colored  or 
dark  red  and  hang  pendent 
in  the  cervical  canal,  ap- 
pearing like  a  plug  in  the 
external  os. 

Endometritis. — A  gon- 
orrheal endometritis,  except 
in  the  acute  form  or  during 
the  puerperal  period,  is  ex- 
tremely rare.  All  conditions 
associated  with  menorrhagia 

Fig.  98. — Acute  Anteflexion  of  the  Uterus  with  Ooni-     t    m    i     i    i   i    i 

CAL  Cervix  tending  to  become  Tapiroid.    A  sign  of     and  collated  Under  the  head 

abnormal  development.     Pregnancy  is  not  apt  to  occur  in  .  /•      , 

these  cases.  01  endometritis  are  factors  m 


ETIOLOGY    IN    THE    FEMALE. 


363 


the  causation  of  sterility.     I  believe,  however,  that  more  cases  of  sterility  are 
caused  by  intra-uterine  medicative  treatments  than  are  cured  by  them. 

Displacements  of  the  Uterus. — Extreme  anteflexion  (see  Fig.  98) 
can  hardly  be  regarded  as  a  cause  of  sterility,  which  lies  rather  in  the  unde- 
veloped state  of  the  uterus 
from  which  the  anteflexion 
itself  arises  than  in  the  po- 
sition of  the  organ.  The 
strong  forward  flexure  of  the 
uterus  must  not  be  confused 
with  the  moderate  forward 
inclination  present  in  every 
sound  woman.  Retroflexion 
of  the  uterus  (see  Fig.  99) 
may  prevent-  conception,  but 
it  does  so  most  frequently  in 
the  case  of  women  who,  hav- 
ing borne  one  child,  acquire 
a  marked  retroflexion  with  a 
descensus.  In  the  case  of  a 
nullipara  it  is  wise  to  be  ex- 
tremely   guarded    as    to    the 

prognosis  of  cure   of  a   Steril-    Fig.    99. — Acute  Retroflexion  of  the  Uterus  which  is 
•  ,,■11  1       ,1  Sometimes  the  Cause  of  Sterility,  but  more  often  Oc- 

lly  tnrOUgn  measures  aaapxea  casions  Abortion  in  the  Early  Months. 

to  relieve  the  retroflexion. 

Infantile  or  Puerile  Uterus. — Women  with  scanty  or  irregular 
menstruation  due  to  a  small  uterus,  of  infantile  or  puerile  form,  rarely  con- 
ceive at  all.  Such  a  uterus,  however,  must  not  be  confused  with  one  which  is 
merely  slightly  smaller  than  the  average.  In  the  infantile  type  the  body  of 
the  womb  is  tiny,  the  cervix  disproportionately  large,  and  the  ovaries  also 
infantile  (see  Fig.  58,  p.  150). 

Myomatous  Tumors  of  the  Uterus. — Sterility  is  so  often  asso- 
ciated with  myomata  that  there  can  be  no  doubt  of  a  causal  relationship  between 
the  two.  Many  women  in  whom  myomata  develop  at  an  early  age  never  con- 
ceive at  all ;  others  conceive  and  abort ;  and  others,  again,  who  apply  to  the 
physician  for  relief  from  large  myomata  when  they  are  in  the  late  thirties  or 
early  forties,  give  a  history  of  having  borne  one  or  two  children.  When  we 
consider  the  disturbances  of  menstruation  which  exist  in  such  cases,  the  watery 
discharges  from  the  mucosa,  and  the  changes  in  the  size  and  form  of  the  uterus, 
together  with  the  frequent  displacements  of  the  tubal  orifices,  the  compression 
and  distortion  of  the  lumen  of  the  tubes  and  the  frequently  associated  disease 
of  the  adnexa,  we  wonder  that  such  women  should  conceive  at  all.  Olshausen, 
who  has  written  more  than  any  living  authority  on  myomata,  collected  1,731 
cases  from  various  sources,   and  found  on  analyzing  them  that  30  per  cent 


364  STEKILITY. 

were  sterile.  These  figures,  however,  are  probably  not  absolute.  Scborler,  fol- 
lowing, as  I  have  done  in  portions  of  this  chapter,  the  excellent  work  of  F. 
Schenk  (loc.  cit.),  found  in  a  statistical  examination  of  253  cases  that  sterility 
prevailed  in  9  per  cent  of  the  polypoid  myomata;  in  18.70  per  cent  of  the 
cervical:  iu  24.7  per  cent  of  the  interstitial;  in  38.8  per  cent  of  the  submucous; 
and  in  47.8  per  cent  of  the  subserous.  Yon  Winckel  found  that  of  108  cases 
examined  bv  him,  41.6  per  cent  had  had  only  one  child.  These  figures,  how- 
ever, are  not  in  accordance  with  the  general  vital  statistics  of  Saxony,  which 
showed  only  22.7  per  cent  of  oue-child  marriages  in  general. 

After  this  apparently  unanimous  agreement  touching  the  causal  relation- 
ship of  myomata  to  fertility,  Hofmeier  investigated  327  myoma  cases  and 
reached  utterly  different  conclusions.  He  found,  for  example,  that  while  20.5 
per  cent  of  this  group  was  sterile,  15.2  per  cent  of  all  his  gynecological  cases 
was  sterile  also.  Thinking  it  hardly  permissible  to  draw  the  conclusion  that 
nivomata  stood  in  direct  causal  relationship  to  the  sterility,  he  pointed  out 
that  the  average  age  of  the  women  in  it  was  forty-two  years  and  that  the 
sterile  marriages  had  lasted,  on  an  average,  sixteen  years.  He  considered  it 
improbable  that  the  fibroid  could  have  begun  to  cause  the  sterility  as  early  as 
the  twenty-sixth  year  in  the  absence  of  any  symptoms ;  and  therefore  he  was 
of  opinion  that  as  the  sterility  almost  invariably  dated  from  a  time  of  life 
wlieu  it  was  highly  improbable  that  myomata  existed  they  could  not  be  sup- 
posed to  exercise  any  influence  upon  its  causation.  For  instance,  out  of  326 
women  with  myomata,  202  had  had  children,  an  average  of  3.2  to  each  woman. 
Xow  the  average  of  all  the  married  women  in  Bavaria,  Saxony,  and  Prussia, 
is  4.5  per  cent,  so  that  the  difl^erence  is  not  great.  Here,  also,  Hofmeier  con- 
siders that  the  sterility  tegins  too  far  back  to  have  been  influenced  by  the 
myoma  appearing  so  many  years  afterward. 

Hofmeier  follows  another  line  of  argument  when  he  notes  that  out  of  503 
cases  of  primary  and  secondary  sterility,  where  there  were  no  children,  or  only 
a  sin2:le  birth  occurred  within  the  first  five  years  of  married  life,  there  were 
onlv  7  cases  with  fibroids,  and  of  these  7,  the  sterility  in  4  was  explicable  on 
other  grounds.  On  the  other  hand,  Hofmeier  claims  that  the  presence  of 
mvomata  in  women  of  more  advanced  age  actually  favors  conception,  as  he 
found  that  in  a  series  of  23  pregnancies  complicated  with  myomata,  only  one 
was  under  thirty,  while  13  were  lietween  forty  and  fortv-seven  years  of  age. 
He  claims  that  this  group  of  cases  is  evidence  that  myomata  are  the  cause  of 
an  increased  activity  of  the  whole  sexual  apparatus,  not  of  the  ovaries  alone, 
and  that  this  is  the  reason  the  sexual  organs  preserve  their  function  so  much 
longer  than  is  usual  in  cases  of  fibroids. 

This  question  is  still  the  subject  of  discussion,  but  in  my  opinion,  the 
following  facts  may  be  considered  as  established  in  regard  to  it: 

(1)  That  the  presence  of  fibroid  tumors  acts  as  a  hindrance  to  conception 
and  this  hindrance  becomes  greater  as  the  tumors  increase  in  numbers  and 
in  size. 


ETIOLOGY    IN    THE    FEMALE.  365 

(2)  That  the  influence  of  fibroid  tumors  is  felt  long  before  they  are  recog- 
nized clinically,  and  that  they  may  prevent  conception  while  still  of  small  size, 
that  is  to  say,  twelve  or  fifteen  years  before  they  are  perceptible. 

(3)  That  they  tend  to  induce  abortion. 

(4)  That  while  fibroid  tumors,  as  a  rule,  are  an  obstacle  to  pregnancy,  it 
may  occur  in  spite  of  them,  even  in  advanced  cases.  Such  cases  always  come 
before  the  attention  of  the  gynecologist. 

(5)  That  one  common  cause  of  the  large  amount  of  sterility  in  women 
with  fibroids  is  the  tubal  and  ovarian  disease  so  often  associated  with  them. 

One  important  point  which  must  be  borne  in  mind  in  this  connection  is 
that  a  ease  of  sterility,  otherwise  inexplicable,  may  be  due  to  small  myomata 
which  are  discovered  only  upon  a  most  searching  examination.  Furthermore, 
in  cases  of  sterility  where  the  husband  is  sound  and  no  apparent  cause  for 
the  condition  can  be  found  in  the  wife,  a  fibroid  tumor  should  be  suspected 
if  the  uterus  is  clearly  larger  than  normal  and  somewhat  irregular  in  form. 

Diseases  of  the  Adnexa. — This  is  an  interesting  group  of  cases  belonging 
to  a  class  which  are  peculiarly  difficult  to  investigate  on  account  of  the  inac- 
cessibility of  the  organs,  namely,  those  cases  in  which  the  sterility  is  due  to 
disease  of  the  uterine  tubes  or  the  ovaries.  It  is  because  it  is  difficult  to  get 
at  these  organs  and  therefore  to  obtain  an  accurate  knowledge  of  their  condi- 
tion that  they  are  frequently  forgotten  in  the  clinical  examination. 

Maldevelopment  of  the  uterine  tubes  is  sometimes  the  cause  of 
sterility.  Such  tubes  are  unusually  long,  often  tortuous,  and  with  little  or 
no  distinction  between  isthmus  and  ampulla,  a  condition  which  has  also  been 
reckoned  among  the  causes  of  extra-uterine  pregnancy.  Again,  the  lumen  of 
the  tubes  may  be  compressed  by  a  fibroid  tumor  and  they  are  liable  to  be  dis- 
torted and  impeded  in  their  movements  by  common  peritoneal  adhesions  as 
well  as  bound  down  and  flexed  by  them.  A  mild  attack  of  gonorrhea,  which 
passes  out  into  the  pelvic  peritoneum  through  the  tubes,  is  sure  to  be  followed 
by  more  or  less  extensive  adhesions  involving  these  delicate  structures  and  inter- 
fering with  their  function.  In  the  case  of  hydrosalpinx  the  lumen  of  the 
tube  is  completely  occluded,  so  that  no  ova  can  be  transmitted  to  the  uterus 
and  sterility  is  the  inevitable  result.  Again,  a  suppurative  infection  of 
the  uterine  tubes  (pyosalpinx)  is  often  an  efficient  cause  of  sterility,  and 
when  it  occurs  in  a  woman  who  has  never  borne  children,  it  is  usually  the 
result  of  a  gonorrheal  infection.  I  have  just  examined  a  woman,  married 
eight  years,  without  children  and  exceedingly  anxious  to  have  them,  who  is 
suffering  from  a  large  abscess  of  the  right  tube  bulging  forward  into  the 
abdominal  cavity  under  the  abdominal  wall  as  well  as  a  smaller  one  of  the 
left  tube. 

Diseases  of  the  ovary  are  not  often  a  cause  of  sterility.  The  ovary 
is  peculiarly  persistent  in  the  performance  of  its  function  from  puberty  to  the 
menopause.  When  the  other  structures  in  the  sexual  apparatus  are  mal- 
developed,  the  ovaries  may  be  elongate  and  smooth,  with  no  follicles  of  an 


366 


STERILITY. 


infantile  type  (see  Tig.  58,  i\  150).  Large  Graafian  cysts,  two  inches 
or  more  in  diameter,  may  be  associated  with  sterility,  but  liow  far  they  act  in 
the  prevention  of  conception  is  not  yet  determined.  Blood  cysts  of  the 
ovary  are  more  serious  hindrances,  on  account  of  the  associated  pelvic  peri- 
tonitis imbedding  both  ovaries  and  tubes.  Ovarian  tumors,  both  cystic 
and  dermoid,  are  an  obstacle  to  conception,  though  they  do  not  form  an  actual 
barrier  to  it.  The  most  common  cause  interfering  with  the  function  of  the 
ovary  and  preventing  the  extrusion  of  the  ovum  or  its  reception  and  trans- 
mission by  the  tube,  is  a  pelvic  peritonitis,  due  to  an  infection  travel- 
ling through  the  uterus,  out  through  the  tubes,  and  onward  to  the  pelvic  peri- 
toneum. The  ovary,  under 
these  conditions,  becomes 
completely  embedded  in  a 
mass  of  adhesions,  which 
may  so  far  interfere  with 
its  circulation  as  to  cause 
atrophj".  Cases  of  ovarian 
abscess  are  rare  and  do 
not  call  for  consideration  in 
connection  with  sterility. 

A  parovarian  cyst, 
such  as  is  often  found  be- 
tween the  outer  extremity 
of  the  uterine  tube  and  the 
ovary,  serves  to  fix,  splint, 
and  flatten  the  fimbriated 
extremity  and  to  push  it 
away  from  the  ovary  (see 
Fig.  100).  This  condition 
would  seem  almost  of  neces- 
sity to  prevent  the  ovum 
from  reaching  the  tube  and 
the  uterus,  for  which  reason  I  present  the  figure.  Positive  evidence  that  it 
does  so,  however,  is  not  as  yet  forthcoming. 

General  Diseases  as  a  Cause  of  Sterility. — Many  systemic  affections  are  so 
constantly  found  associated  with  sterility  as  to  demonstrate  conclusively  the 
existence  of  a  causal  relationship.  The  etiologic  connection,  in  some  cases,  is 
quite  clear,  as  when  some  general  disease  causes  an  atrophy  of  the  uterus, 
that  is  to  say,  a  withering  in  size  of  an  organ  which  was  previously  of  normal 
dimensions.  A  very  severe  labor  may  also  cause  uterine  atrophy  and 
thus  occasion  a  one-child  sterility.  Other  causes  are  tuberculosis  and 
nephritis,  as  well  as  such  acute  infectious  diseases  as  mumps,  scarlatina, 
and  acute  rheumatism.  The  acute  infectious  diseases  may  also  bring 
about  a   premature   atrophy   of  the   ovaries   (see  Chap.  X).     Conspicu- 


FiG.  100. — One  of  the  Possible  Causes  of  Steeility.  A 
monocystic  tumor,  with  clear  watery  contents,  splinting 
the  tube  and  separating  it  widely  from  the  ovary. 


ETIOLOGY    IN    THE    FEMALE.  367 

ous  among  the  affections  which  may  canse  atropliy  of  the  pelvic  organs  and 
consequent  sterility  are  the  chronic  poisonings,  alcoholism  and  morphin- 
ism. In  both  these  conditions  it  is  not  uncommon  to  find  a  disappearance 
of  the  menstrual  function  for  months  at  a  time.  Patients  with  aggravated 
heart  disease  also  do  not  often  become  pregnant.  Excessive  fat  seri- 
ously interferes  with  the  function  of  the  sexual  organs ;  for  example,  out  of 
two  hundred  and  fifteen  such  cases  Kisch  found  twenty-one  per  cent  sterile. 
Gebhard  associates  the  changes  in  the  ovaries  under  these  circumstances  with 
those  in  the  thyroid  gland  and  suprarenal  bodies.  An  enormous  accumulation 
of  fat  may  sometimes  interfere  with  conception  through  the  mechanical  hin- 
drance which  it  presents.  The  relation  of  obesity  to  changes  in  the  sexual 
organs  is  discussed  in  Chapter  VIII. 

Violent  psychical  disturbance  may  be  the  cause  of  the  disappear- 
ance of  menstruation  for  a  long  period  of  time ;  such  a  case,  for  instance,  is 
cited  by  Kisch,  in  which  a  woman  went  ten  years  without  menstruating  or 
conception,  after  seeing  a  child  run  over.  The  association  of  chlorosis  with 
the  disturbances  of  menstruation  is  interesting.  According  to  Virchow  there 
are  tv/o  varieties  of  this  condition,  one  in  which  the  sexual  organs  are  imper- 
fectly developed  and  another  in  which  there  appears  to  be  an  excess  of  devel- 
opment ;  in  the  former  group  there  is  a  complete  amenorrhea  and  in  the  latter 
a  monorrhagia   (see  Chap.  VI). 

Dyspareunia. — It  is  a  moot  question  how  far  the  absence  of  sexual 
desire  (anaphrodisia)  is  responsible  for  sterility.  If  a  sterile  woman  has 
no  desire  for  the  relationship  and  no  satisfaction  in  its  completion,  she  is  sure 
to  regard  the  fact  as  the  cause  of  her  disappointment  and  to  give  it  a  promi- 
nent place  in  her  complaint.  Kisch  considers  that  the  sexual  feeling  is  a 
matter  of  importance,  as  he  found  twenty-six  cases  in  which  it  was  absent  out 
of  sixty-nine  sterile  women.  Hegar,  on  the  other  hand,  considers  that  the 
sexual  inclination  of  women  in  general  is,  on  the  average,  but  slight  and  that 
it  plays  but  little  part  in  the  question  of  conception.  This  group  of  cases  may 
be  divided,  according  to  Strassmann,  into  three  classes,  namely : 

(1)  Those  in  which  the  sexual  feeling  is  simply  absent. 

(2)  Those  in  which  there  is  a  feeling  of  repulsion. 

(3)  Those  in  which  the  relation  is  actually  painful. 

I  am  myself  inclined  to  believe  that  the  simple  absence  of  sexual  desire, 
when  the  organs  of  generation  are  normal,  has  little  or  nothing  to  do  with 
sterility.  Sanger,  quoted  by  Schenk,  does  not  mention  it  once  in  a  series  of 
four  hundred  and  eighteen  cases. 

Repulsion,  on  the  other  hand,  may  cause  sterility,  as  in  a  case  under 
my  own  care,  where  I  discovered  a  rigid  double  liymen  in  a  woman  who  had 
been  married  for  a  number  of  years.  She  told  me  that  she  had  a  strong 
repulsion  toward  the  sexual  act  and  that  her  husband  had  agreed  not  to  touch 


36g  STEKILITT. 

lier.  In  auotlier  iiistancp,  a  beantifnl  voimg  girl  refused  throughout  some 
fifteen  years  of  married  life  to  allow  her  aged  husband  to  touch  her,  on  account 
of  his  awkward  manner  of  approach. 

Pain  is  operative  as  a  cause  of  sterility  when,  owing  to  some  local  affec- 
tion at  the  vaginal  orifice  or  above  the  vault,  the  distress  excited  by  the  marital 
approach  is  so  marked  that  the  husband  either  occupies  a  separate  bed  or  at 
least  approaches  his  wife  only  at  long  intervals.  I  have  also  seen  cases  in 
which  a  decided  pain  was  complained  of,  particularly  on  the  left  side  above 
the  vaginal  canal,  where  nothing  abnormal  whatever  could  be  discovered, 
although  sometimes  the  suffering  could  be  reproduced  by  digital  pressure. 
Such  cases  belong  to  the  neuroses  and  are  met  with  in  the  class  of  women  who 
complain  excessively  of  pain  in  the  course  of  examination  of  the  pelvic  organs, 
although  no  disease  can  be  found.  The  occurrence  of  a  localized  pain,  situ- 
ated deep  within  the  pelvis  and  most  frequently  felt  toward  the  end  of  the 
sexual  act,  should  always  excite  suspicion  of  a  pelvic  inflammatory  affection 
and  lead  to  a  searching  examination. 

Vaginismus,  a  term  proposed  by  Marion  Sims,  was  used  by  him  to 
designate  a  condition  found  in  a  certain  class  of  women,  who  shrink  from,  or 
absolutely  avoid  coitus  on  account  of  a  hyperesthesia  of  the  vulva  in  the  neigh- 
borhood of  the  hymen  which  induces  strong  muscular  contractions.  Sometimes 
the  nervous  apprehension  is  so  great  that  the  adductor  muscles  are  thrown  into 
a  spasmodic  condition,  preventing  the  separation  of  the  thighs ;  at  others  a 
lively  nervous  hysterical  condition  is  excited,  associated  with  a  complete  con- 
traction of  the  sphincter  vaginae  and  levator  ani  which  hinders  any  approach 
(see  Chap.  XII).  This  group  of  cases  must  not  be  confounded,  however,  with 
those  in  which  the  patient  is  simply  hysterical  and  seeks  to  avoid  the  sexual 
act  from  lack  of  desire,  nor  with  those  other  cases  where  the  hjoneneal  vault 
is  rendered  exquisitely  tender  by  little  superficial  ulcerative  areas,  a  well- 
defined  pathological  condition  of  a  gross  character.  Yeit  considers  that  in 
some  cases,  where  the  vaginismus  is  due  to  a  neurosis  pure  and  simple,  the 
condition  is  often  attributable  to  masturbation  inducing  an  excessive  local 
irritability.  I  have  not,  myself,  seen  any  instances  which  I  could  attribute  to 
this  cause. 

The  marriage  of  cousins  according  to  Mantegazza  and  G.  Darwin, 
cited  by  Schenk,  does  not  seem  to  occasion  sterility.  Goehlert,  however,  quoted 
by  the  same  vrriter,  concludes  from  a  study  of  the  royal  families  of  Europe 
that  blood  relationship  in  marriage,  repeated  for  generations,  is  a  serious  ele- 
ment in  its  causation,  showing  that  of  one  hundred  and  eighteen  marriages 
related  by  blood  in  the  dynasty  of  the  Capetinger  forty-one  were  sterile ;  in  the 
house  of  Wettin  seven  out  of  twenty-eight ;  in  "Wittelsbach  nine  out  of  twenty- 
nine  ;  in  that  of  Hapsburg-Lothringen  eight  out  of  twenty-five ;  that  is  to  say, 
out  of  two  hundred  marriages  between  blood  relations,  sixty-five  or  thirty-two 
and  five-tenths  per  cent  were  sterile. 


TREATMENT.  369 


TREATMENT. 


The  first  step  in  the  treatment  of  sterility  is  to  investigate  the  canse,  and 
the  first  thing  to  be  done  in  such  an  investigation  is  to  inquire  into  the  con- 
dition of  the  would-be  mother,  remembering  that  only  grave  and  for  the  most 
part  self-evident  diseases,  whether  local  or  constitutional  (except  diabetes  and 
nephritis),  are  likely  to  hinder  conception.  The  next  point  to  be  considered 
before  planning  a  course  of  treatment,  is  whether  one  or  both  would-be  parents 
are  affected,  and  to  this  end  the  condition  of  the  husband  should  always  be 
investigated.  As  a  rule,  the  husband  should  not  be  questioned  in  the  presence 
of  the  wife,  for  every  man  who  exacts  purity  in  his  wife  in  her  antecedent 
relations  will  naturally  profess  before  her  to  have  lived  up  to  no  lower  stand- 
ard himself. 

When  the  husband  is  questioned  alone,  it  is  worth  while,  in  America  at 
all  events,  to  inquire  whether  his  life  before  marriage  was  one  of  purity  and 
continence.  If  he  admits  illicit  relations,  then  it  is  well  to  ask  whether  he 
has  had  syphilis  or  gonorrhea,  and,  if  he  has  had  gonorrhea,  whether  one  or 
both  testicles  were  affected ;  also  whether  he  had  a  protracted  gleety  discharge 
with  the  gonorrhea,  and  whether  such  a  discharge  was  present  at  the  time  of 
his  marriage.  The  questioner  must  remember  that  many  men,  who  have  stimu- 
lated an  old  and  latent  gonorrhea  into  fresh  activity  in  the  first  months  of 
married  life,  are  inclined  to  consider  the  resulting  discharge  as  nothing  more 
than  the  natural  results  of  excess. 

In  examining  both  the  man  and  his  wife  it  is  well  to  follow  some  scheme, 
like  that  adopted  by  F.  Kehrer  (loc.  cit.,  p.  78),  or  like  a  somewhat  fuller 
outline  such  as  that  which  I  present  on  pages  370  and  371.  A  series  of  records 
kept  on  a  scheme  of  this  kind  would  be  of  great  statistical  value  in  this  country. 

ISTo  matter  what  the  find  in  either  case  both  husband  and  wife  should  always 
be  examined.  If  the  husband  is  found  to  be  at  fault,  the  gynecologist  would  do 
well  to  refer  him  to  a  competent  andrologist  (Sanger)  commonly  known  to-day 
as  a  "  g.-u.  specialist."  Pinard  says  that  the  husband  should  never  be  told  that 
the  case  is  hopeless,  as  he  has  known  two  or  three  to  take  their  own  lives  under 
such  circumstances.  The  physician  may  almost  alwaj's  assure  the  husband 
with  azoo-,  oligo-  or  necrospermia  that  there  is  a  hope  of  his  recovery,  for 
numerous  cases  can  be  recalled,  in  the  hands  of  different  specialists,  in  which 
after  repeated  examinations  a  few  living  sperm  cells  have  been  found  and 
where,  though  long  delayed,  conception  has  taken  place. 

In  making  a  diagnosis  of  the  cause  of  sterility  in  the  woman  preparatory 
to  treatment,  the  examiner  must  bear  in  mind  three  things : 

(1)  Can  any  obstruction  be  discovered  which  is  likely  to  interfere  with 
the  progress  of  the  ovum  to  the  uterus  ? 

(2)  Is  there  any  mechanical  hindrance  which  prevents  the  progress  of 
the  spermatozoa  upward  into  the  cervix,  through  the  uterus,  and  out  into  the 
uterine  tubes,  where  conception  normally  takes  place  ? 

25 


370 


Name. 


Age. 


STERILITY. 


Outline  for  Examination  of  Husband^ 


Year  of  marriage. 


Sexual  history   before  marriage. 


General  appearance  and  present  state  of  healths 


Condition   of  testes  and  epididymis. 


"    vasa  deferentia. 


*'  "    vesicult^  seminales. 


"   prostate  gland. 


Coitus   nortnal  ? 


Average  frequency   of  coitus. 


Condition  of  semen.,  examined  after 


days'  interval  since  last  coitus. 


Manner  in  which  semen  was  obtained. 


Semen   examined 


nuinher   of  hours   after   coitus. 


Manner   in   which   semen   is  preserved. 


Microscopical    examination — Normal.        Nccrospermia,        Oligospermia.        Azoospermia 
Prostatic  cells.      Pus.      Gonococci.      Chobstearine  balls.      Corpora  amylacea. 


treatment.  371 

Outline  for  Examination  of  Wife. 
Name. 

Age. 

Year  of  marriage. 

Pregnancies^  miscarriages. 

General  appearance  and  present  state  of  health. 

Previous  diseases^  especially   of  an   infectious   character. 

Menstrual  history^  as   to  regularity^  duration^  amount^  and  presence  of  pain. 

Leucorrhea^  especially   any  discharge  first   noted  after  7narriage. 

Suspected  abortions. 

Infections  following   abortions. 

Previous   gynecological   affections    and    treatments    directed   to    the    relief  of  sterility    or 
uterine  disease. 

Any  abnormality  about  the  vulva^ 

vagina., 
cervix., 
uterus., 

uterine  tubes., 
ovaries., 
sexual  feeling. 

Diagnosis   of  cause.,   or  probable   cause   of  the  sterility. 


372  STERILITY. 

(3)  Is  tliere  any  endometrial  condition  (polyp,  myoma,  endometritis) 
which  is  likely  to  prevent  the  attachment  of  the  fertilized  ovnm  ? 

He  mnst  then  look  for  any  gross  disease  of  the  vnlva,  vagina,  or  cervix. 
'Next  he  mnst  examine  the  nterns  in  order  to  ascertain  the  presence  of  tumors 
or  displacements ;  and,  finally,  he  must  investigate  the  condition  of  the  ovaries 
to  determine  whether  there  is  any  disease,  characterized  by  enlargement,  already 
evident  on  bimanual  examination.  If  he  finds  no  cause  for  the  sterility  in 
any  of  these  localities,  he  reviews  the  case  for  a  gonorrheal  infection,  tak- 
ing specimens  of  urethral,  vaginal,  or  cervical  secretions  for  microscopical 
examination. 

The  following  conditions  associated  with  a  sterility  are  susceptible  of  relief : 

(1)  Imperforate  hymen. 

(2)  Vaginismus. 

(3)  Eetroflexion. 

(4)  Anteflexion. 

(5)  Endometritis. 

(6)  Stenosis  of  the  cervix. 

(7)  Uterine  polyp. 

(8)  Fibroid  tumor. 

(9)  Parovarian  cyst. 

(10)  Ovarian  and  dermoid  cysts,  when  unilateral. 

(11)  Gonorrheal  infections  of  the  genital  tract  below  the  uterine  tubes  or 
above  the  uterus,  if  one-sided. 

(12)  Various  other  infections,  which  it  is  not  necessary  to  differentiate. 
The  conditions  which  are  not  susceptible  of  relief  are  these: 

(1)  Absence  of  the  vagina  and  of  the  uterus. 

(2)  Infantile  uterus  and  ovaries. 

(3)  Extensive  fibroid  tumors  of  the  uterus. 

(4)  Extensive  inflammatory  changes. 

If  nothing  can  be  found  on  making  the  usual  careful  bimanual  examina- 
tion, the  patient  should  be  anesthetized  and  the  pelvis  explored.  If  no  fault 
is  then  found,  a  thorough  dilatation  of  the  cervix  should  be  done  and,  if  called 
for,  a  curettage  (see  Chaps.  IV  and  VII). 

An  imperforate  hymen  is  best  treated  by  complete  excision  (see 
Chap.  VI).  If  there  is  any  vaginismus  it  must  be  treated  as  laid  down 
in  Chapter  XII. 

In  sterility  of  long  standing,  a  retroflexion  ought  to  be  corrected. 
First  a  pessary  may  be  tried,  and  then,  if  that  does  not  relieve  the  situation, 
an  operation,  drawing  the  uterus  forward  by  its  round  ligaments.  Ante- 
flexion of  an  extreme  character  is  rather  a  sig-n  of  maldevelopment 
than  a  mere  postural  disorder.  Here  the  cervix  may  be  dilated  and  then 
divided  back  to  the  vault  in  the  median  line.  A  plug  of  gauze  left  in  for  a 
few  days  will  serve  to  keep  the  wound  open. 

Endometrial    conditions    are    best    treated    by    curettage.       Cicatricial 


TREATMENT.  373 

stenosis  is  still  the  commonest  discoverable  canse  of  sterility,  and  when  no 
other  condition  can  be  found  to  account  for  it,  it  is  safe  to  consider  this  the 
probable  hindrance.  The  dilatation  for  its  relief  should  be  done  thoroughly, 
at  one  sitting,  using  a  small,  a  medium,  and  a  large  dilator  in  such  a  manner 
as  to  open  the  cervix  widely,  without  tearing  it. 

The  details  of  the  operation  are  described  in  Chapter  IV,  but  I  add  a 
word  of  emphasis  here  in  regard  to  one  or  two  important  points.  The  best 
dilators  for  the  purpose  are  the  parallel  dilators  of  the  Goodell-Ellinger  type. 
The  cervix  should  be  equally  dilated  in  all  directions,  up  to  and  including  the 
internal  os,  until  it  is  sufficiently  stretched  to  admit  a  bougie  eight  to  ten 
millimetres  in  diameter.  I  do  not  think  it  advisable  to  dilate  the  cervix  every 
month.  It  is  wiser  to  correct  the  trouble,  and  then  let  nature  have  a  chance 
to  regulate  her  functions.  N^either  do  I  place  any  great  confidence  in  the  vari- 
ous cutting  operations  practised  on  the  cervix  and  still  less  on  those  more  dan- 
gerous operations  involving  the  cervical  canal  (discission).  I  have  already 
spoken  of  two  precautions  which  should  attend  every  dilating  operation,  which, 
in  my  opinion,  should  never  be  called  "  a  little  operation  "  or  "  no  operation 
at  all " ;  but  it  may  be  well  to  repeat  my  caution  here. 

(1)  The  physician  must  be  sure  that  there  is  no  intrapelvic  inflammation, 
which  would  be  liable  to  be  lighted  up  by  this  manipulation.  I  have  seen  some 
distressing  cases,  in  which  the  patient  was  said  to  have  been  "  perfectly  well 
until  the  doctor  dilated  the  womb,"  after  which  a  latent  infection  flared  up, 
until  the  pelvis  filled  with  pus,  all  in  consequence  of  neglect  of  this  precaution. 

(2)  The  same  care  as  to  cleanliness  of  the  vulva,  the  vagina,  and  the 
instruments  must  be  employed  as  in  a  major  operation.  Carelessness  in  this 
particular  also  may  light  fires  which  can  only  be  extinguished  by  the  sacrifice 
of  all  the  structures  concerned. 

In  most  cases  where  dilatation  of  the  cervical  canal  is  necessary,  the  patient 
suffers  more  or  less  from  dysmenorrhea,  and  curettage  is  called  for  as  well. 
It  is  well,  however,  to  warn  the  patient  that  she  must  not  expect  conception 
to  take  place  at  the  very  next  period,  but  be  content  to  wait  patiently  for  at 
least  a  year. 

A  uterine  polyp  may  be  suspected  as  the  cause  of  the  sterility  when 
the  menstrual  flow  tends  to  be  hemorrhagic,  or  when  the  uterus  is  enlarged, 
or  when  the  polyp  can  be  seen  or  felt  at  the  external  os.  It  should  be  removed 
by  surgical  means. 

Fibroid  tumors  may  be  removed  by  enucleation  rather  than  by  ampu- 
tation of  the  uterus,  with  the  hope  of  subsequent  pregnancy  in  younger  women. 
Out  of  ninety-four  abdominal  myomectomies,  performed  in  my  clinic,  where 
pregnancy  was  hoped  for,  it  occurred  in  thirteen.  Of  this  number  twelve  went 
to  term,  and  one  miscarried.  Out  of  thirteen  vaginal  myomectomies  where 
pregnancy  might  be  looked  for,  it  took  place  in  tM^o. 

Parovarian  cysts,  unless  very  large,  can  be  removed  readily,  sparing 
the  uterine  tube  and  the  ovarv. 


374  STEKILITT. 

When  no  gross  lesion  exists,  gonorrhea  must  be  sought  for.  To  this 
end  a  cover  slip  ought  to  be  taken  in  every  case,  without  exception,  and  exam- 
ined for  intracellular  diplo cocci  (gonococci).  The  discovery  of  gonor- 
rheal infection  gives  the  treatment  a  definite  object,  namely,  that  of  removing 
the  infection  from  its  various  resting  places. 

If  the  disease  has  progTessed  as  far  as  the  peritoneum,  involving  the  ovaries 
in  adhesions  and  converting  the  tubes  into  sacs  (hydro-  or  pyosalpinx)  the 
case  is  not  a  hopeful  one,  as  far  as  the  cure  of  the  sterility  is  concerned.  If 
there  is  pus  in  the  tubes,  the  best  plan  is  to  refer  the  patient  to  a  gynecologist 
who  may  open  them  freely,  and  make  a  wide  drainage  opening  below  into  the 
vagina;  even  under  such  conditions,  conception  may  occur  after  the  parts  have 
recovered  from  the  operation.  Delicate  restorative  ojDorations  done  on  closed 
tubes  are  but  rarely  successful  in  bringing  about  conception.  When  the  gonor- 
rhea affects  the  cervix,  which  is  its  seat  of  predilection,  and  where  next  to 
the  tubes  it  does  most  harm,  the  best  plan  is  to  burn  it  out  with  a  Paquelin 
cautery  or  scrape  it  out  with  a  Craig's  curette,  as  described  in  Chapter  XL 
In  one  of  my  patients,  thirty-two  years  of  age,  who  had  an  acquired  sterility 
of  twelve  years'  standing,  I  found  a  large  everted  cervix  pouring  out  a  muco- 
purulent secretion.  Three  cauterizations  with  a  Paquelin  cautery,  after  Hun- 
ner's  method,  cured  the  discharge  and  fifteen  months  later  she  bore  a  healthy 
child  (Mrs.  S.,  Case-book  XYI,  Xo.  84,  Jan.,  1906).  The  vagina  should  be 
treated  as  described  in  Chapter  XI,  or  as  recommended  by  Sanger,  with  a 
fifty  per  cent  solution  of  chloride  of  zinc,  applied  thoroughly  with  a  large 
cotton  applicator,  care  being  taken  not  to  burn  the  external  genitals.  Follow- 
ing this  application  a  loose  pack  of  gauze,  coated  with  zinc  oxide  salve,  may 
be  inserted  and  left  in  situ  for  twelve  to  eighteen  hours.  Any  gonorrheal 
affection  of  the  external  glands  should  be  relieved,  and  an  infected  vaginal 
gland  should  be  incised.  Skene's  glands  (para-urethral)  should  be  probed  and 
cut  down  into  through  the  vagina,  so  that  they  are  opened  and  drained  to  the 
very  bottom.  This  little  operation  may  be  done  under  a  two  per  cent  solution 
of  cocain  injected  into  the  adjacent  tissues. 


CHAPTEK    XVI. 
GONOCOCCUS  INFECTION   (GONORRHEA). 

History  and  general  considerations,  p.  375.  Prevalence,  p.  376.  Organs  usually  affected,  p.  376. 
A.  constitutional  as  well  as  a  local  disease,  p.  377.  Description  of  the  gonococcus,  p.  377. 
Different  tissues  in  which  the  gonococcus  is  found,  p.  378.  Gonotoxine,  p.  379.  Curability 
of  gonococcus  infection,  p.  380.  Clinical  course  and  symptoms,  p.  380.  Acute  gonococcus 
infection;  sub-acute  and  chronic  gonococcus  infection,  p.  380.  Vulvo- vaginitis  in  little 
girls,  p.  381.  Latent  gonorrhea,  p.  384.  Gonorrhea  and  marriage,  p.  384.  Diagnosis,  p. 
384.     Treatment,  p.  386. 

GoN-ococcus  infection  is  a  Letter  name  than  gonorrhea,  time- 
honored  though  the  latter  is,  because  it  does  not  carry  with  it  necessarily  the 
stigma  of  a  venereal  disease.  This  consideration  is  especially  important  in 
vulvo-vaginitis  in  children  where  there  is  often  no  suspicion  of  a  direct  venereal 
origin  of  the  infection. 

History. — The  disease  is  of  great  antiquity;  it  was  common  among  the 
Greeks  and  Komans,  and  even  before  that  time  there  are  references  to  it  in 
literature.  In  the  fifteenth  chapter  of  Leviticus  careful  instructions  are  given 
to  the  Israelites  as  to  the  measures  to  be  adopted  to  avoid  contagion  from  a 
running  from  the  urethra.  It  is  not  probable  that  the  nature  of  the  disease 
was  fully  appreciated  until  recent  times,  the  term  gonorrhea  signifying  a  flow 
of  semen  (y6vo<f,  semen,  poia,  flow).  In  the  year  1857  Bernutz  and  Goupil 
published  an  authoritative  treatise  on  the  influence  of  gonorrhea  in  the  causa- 
tion of  pelvic  peritonitis  and  salpingitis.  Its  recognition  as  a  frequent 
cause  of  serious  uterine  diseases  was  not  determined,  however,  until 
Emil  N'oeggerath  issued  a  monograph  on  the  subject  in  1872.  His  paper  on 
latent  gonorrhea  read  before  the  American  Gynecological  Society  four  years 
later  evoked  a  storm  of  protest  from  the  medical  profession.  He  claimed  that 
gonorrhea  in  the  male  as  well  as  in  the  female  persists  for  life  in  certain  sec- 
tions of  the  organs  of  generation,  notv/ithstanding  its  apparent  cure  in  a  great 
many  instances.  There  is  a  form  of  gonorrhea  in  both  sexes  called  latent 
gonorrhea,  which  may  infect  a  healthy  person  with  either  acute  gonor- 
rhea or  gleet.  Latent  gonorrhea  in  the  female  manifests  itself  as  acute, 
chronic,  or  recurrent  perimetritis,  or  ovaritis,  or  as  catarrh 
of  certain  sections  of  the  genital  organs  ;  finally,  about  ninety  per 
cent  of  sterile  women  are  married  to  husbands  wlio  have  suffered  from  gonor- 
rhea either  previous  to,  or  during,  married  life. 

ISToeggerath's  views,  although  extreme,  are,  in  the  main,  held  to  be  true  to- 
day.    The  discovery  of  the   gonococcus   by  A.  JSTeisser  in  1879  served  to  put 

375 


376  GONOCOCCTJS    INTECTION. 

the  investigation  of  the  prevalence  of  the  disease  in  women,  as  Tvell  as  its  varied 
manifestations,  on  a  proper  scientific  footing.  It  was  nearly  twenty  years, 
however,  before  many  observations  based  on  exact  bacteriological  knowledge 
were  put  on  record. 

Prevalence. —  The  prevalence  of  gonococcns  infection  in  women  varies  within 
wide  limits,  according  to  the  views  of  different  gynecologists.  It  is  by  no  means 
uncommon  in  little  girls,  esj)ecially  in  institutions.  This  subject  will  be  taken 
up  in  some  detail  farther  on.  It  is  sufiicient  to  say  here  that  most  of  the  cases 
of  purulent  vuNo-vaginitis  in  children  are  now  believed  to  be  of  gono coccus 
origin.  I  have  just  noted  the  conclusions  of  Xoeggerath  as  to  the  frequency  of 
this  disease.  Lomer  found  the  diplococcus  in  sixty  per  cent  of  the  gynecolog- 
ical patients  of  Schroeder's  clinic,  Sanger  and  Schwartz  {Centrhl.  f.  Gyn., 
1896,  vol.  20,  J),  1075)  put  the  percentage  of  gonorrhea  among  all  their  patients, 
hospital  and  private,  as  low  as  twelve  per  cent.  Taylor,  viewing  the  matter  from 
the  standpoint  of  the  venereal  specialist,  says  that  twelve  per  cent  is  a  con- 
servative estimate  of  the  gonorrheal  origin  of  all  uterine  diseases. 

This  great  diversity  of  opinion  can  be  accounted  for  in  several  ways.  First, 
the  difficulty  of  finding  the  scattered  organisms  in  the  chronic  cases.  In  the 
acute  cases  and  under  favorable  circumstances  the  gonococci  are  often  not 
very  numerous,  only  four  to  a  dozen  being  found  in  one  microscopical  field. 
Second,  we  know  that  under  certain  conditions  the  cocci  die,  whether  from 
lack  of  suitable  nutrient  material,  from  the  activity  of  the  phagocytes,  or  from 
other  causes.  But  although  they  are  dead,  the  tissues  in  which  they  occur  are 
still  infected,  perhaps  because  of  the  "  gonotoxine  "  generated  in  the  dead  cells. 
Third,  the  class  of  patients  treated.  We  should  expect  to  find  gonorrhea 
most  common  among  prostitutes,  and  statistics  prove  this  to  be  the  case.  Among 
five  hundred  and  thirty-three  j3rostitutes,  sick  and  well,  examined  in  the  regTilar 
routine  by  Huber  (Wien.  med.  Wochenschr.,  1898,  p.  21)  fifty-nine  and  six- 
tenths  per  cent  had  gonorrhea.  Prowe  (Centrhl.  f.  Gyn.,  1901,  vol,  25,  p.  82) 
found  gonorrhea  in  seventy-six  and  nine-tenths  per  cent  of  four  hundred  and 
seven  sick  prostitutes  in  San  Salvador,  Central  America.  Zweifel  thought  the 
number  of  women  in  his  private  practice  who  were  ill  because  of  the  gonococ- 
cns was  from  ten  to  eleven  per  cent.  Some  writers  place  the  percentage  among 
private  patients  as  high  as  twenty  per  cent.  Obviously  information  on  this 
point  is  difficult  to  obtain,  for  few  statistics  are  published,  physicians  not  caring 
to  go  on  record. 

Organs  TJsually  Affected. — The  organs  in  woman  usually  affected  by  the 
gonococcns  are  the  vulva,  urethra,  vagina,  uterine  canal,  and 
uterine  tubes  (see  Fig,  101),  Destructive  inflammation  of  the  tubes  and 
ovaries  with  peritonitis  is  common,  Gonococcns  inflammation  of  the  rectum 
and  gonococcns  infection  of  the  bladder  with  secondary  ascending  in- 
ilammation    of    the    ureters    and   kidneys    is  not  rare. 

That  the  disease  is  a  serious  one  and  rebellious  to  treatment  there  can  be  no 
doubt.     The  Committee  of  Seven  of  the  American  Medical  Association,  in  a 


OKGANS    USUALLY    AFFECTED    BY    GONOEEHEA. 


377 


recent  report  to  the  Association,  asserted  that  eighty  per  cent  of  the  deaths  from 
female  pelvic  disease  are  due  to  gonococcus  infection.  We  have  to  consider  not 
only  the  manifestations  of  the  disease  in  the  genito-nrinary  organs  hnt  also  its 
effect  on  distant  organs,  such  as  gonococcus  arthritis,  especially  of  the 
knee  joint,  and  its  effect  upon  the  system,  in  causing  anemia  and  debility.  F.  E,. 
Sturgis  (Amer.  Jour.  Urol.,  IST.  Y.,  1904-5,  vol.  1,  p.  349)   draws  a  parallel 


Salpingitis 


Pelv.  peritonitis 


?yo  salpinx 


Endocerviciti 


Vaginitis 


Absc.  ofBarth.gX. 


Fig.  lOL — The  Various  Sites  in  which  the  Gonorrheal  Organism  is  Apt  to  become  Implanted 
AND  Linger.  These  are:  Skene's  glands;  Bartholin's  glands;  the  vagina  (in  the  young);  the 
cervix;  the  endometrium;  the  uterine  tubes;  and  the  ovarian  follicles.  The  whorled  arrows 
mark  the  sites  in  which  the  infection  lingers  by  preference. 

between  the  constitutional  effects  of  syphilis  and  gonorrhea.  He  considers  that 
many  of  the  same  organs  are  attacked  by  both  diseases,  and  that  gonorrhea 
may  be  Jikened  to  syphilis  in  the  seriousness  of  the  systemic  disturbances  it 
causes,  not  the  least  of  these  being  impoverishment  of  the  blood  state 
and  rheumatism,  with  attendant  gonococcus  endocarditis.  Out  of 
an  ample  experience  as  clinical  professor  of  venereal  diseases  in  the  University 
of  the  City  of  ]^ew  York,  he  deprecates  the  silly  belief  of  those  who  consider 
gonorrhea  as  no  more  important  than  a  cold  in  the  head. 

Description  of  the  Gonococcus. — The  gonococcus  according  to  E.  Bumm  (J. 
Veit's  "  Handbu.ch  der  Gynakologie,"  vol.  1,  p.  430),  who  has  studied  it  ex- 
tensively, belongs  to  the  diplo coccus  group  as  far  as  its  form  goes,  and  to 
the  staphylococcus  family  in  its  mode  of  development.  It  is  a  pus-pro- 
ducing bacterium  affecting  chiefly  columnar  epithelium.  The  accompanying 
figure  shows  the  shape  of  the  coccus,  not  unlike  two  grains  of  coffee  with  the 
furrows  on  the  concave  sides,  each  half  being  generally  separated  from  its  sister 
half  by  a  well-marked  interval  (see  Fig.  102).  Sometimes  the  two  halves  are 
joined  at  one  end  as  shown,  and  sometimes  they  are  of  irregular  size  (Maslov- 
ski).     The   coccus   measures  about  one  and  a  quarter  millimetres  in  diameter. 


378 


GONOCOCCUS    IKTECTION. 


s 

c»e9 

CI  €9 

CI  CI 
CI  CI 

102 


103 


The    GoxoRRHE.iL, 


Figs.    102    and    103. 

Orgaxism,  Goxococcus  of  Neisser 
(102)  A  series  of  forms  of  individual 
cocci,  biscuit-shaped  and  double,  highly- 
magnified;  (103)  groups  of  cocci  which 
are  characteristic,  especially  the  pres- 
ence of  the  cocci  within  pus  cells  above. 
(From  Veit,  "Handbuch  der  Gynakolo- 
gie,"  Bd.  I,  p.  430.) 


It  is  sharply  differentiated  in  appearance  from  the  white  corpuscle  in  which 
it  has  its  habitat,  so  that  it  can  be  recognized  with  ease.  It  increases  by  division 
in  vertical  planes  to  form  clusters,  never  chains,  of  new    cocci.     It  takes  the 

aniline  dyes  with  great  readiness,  but  al- 
wajs  loses  its  color  by  the  Gram  method  of 
decolorizing.  In  secretions  it  usually  lies 
within  the  protoplasm  of  the  pus  cell,  al- 
though occasionally  it  is  found  free. 

Tissues  in  Which.  Gonococcus  Is  Found. — 
The  gonococctis  has  an  especial  affinity 
for  the  mucous  membranes  of  man.  It  is 
not,  as  formerly  thought,  limited  in  its  place 
of  gTowth  to  the  columnar  epithelium.  It 
has  been  found  in  the  sub-mucous  tissues 
of  the  vagina  by  Mandl ;  in  squamous  epi- 
thelium by  Bumm,  Teuton,  and  others ;  in 
the  thrombosed  blood  vessels  of  the  bladder, 
in  the  serosa  of  the  peritoneum,  and  in  the 
substance  of  the  ovary  by  E.  Wertheim;  in  the  connective  tissue  of  the  uterine 
tubes  by  Kraus ;  in  the  rectal  mucous  membrane  by  Fritsch ;  in  the  uterine  mus- 
cle by  Madlener  and  Menge ;  in  the  decidua  and  placenta  of  a  nine  months  preg- 
nancy by  ]\Iaslovski,  and  in  the  urine  of  cystitis  by  Melchoir.  Kronig  (ref.  to 
by  F.  Staehler,  2Ionatss.  f.  Geh.  unci  Gyn.,  1903,  voL  17,  p.  77)  found  gono- 
cocci  in  the  lochia  of  over  ten  per  cent  of  two  hundred  and  ninety-six  lying-in 
women  who  had  had  child-bed  fever.  Lobenstine  and  Harrar  {Bull.  Lyijig-in 
Hosp.,  ]Sr.  Y.,  Dec,  1906)  found  that  the  average  birth-weight  of  the  babies  of 
"  gonorrheal  mothers  "  is  less  than  that  of  babies  of  "  normal  mothers."  Their 
deductions  were  based  on  the  observation  of  fifty  babies  of  gonorrheal  mothers 
without  fever,  fifty  babies  of  gonorrheal  mothers  with  high  temperatures,  and 
one  hundred  and  fifty  of  normal  mothers.  Xot  only  is  the  average  weight  less, 
but  there  is  a  greater  permanent  loss,  babies  of  gonorrheal  parentage  gaining 
at  the  end  of  ten  days  only  ten  and  nine-tenths  per  cent,  while  babies  of  nor- 
mal mothers  gain  forty-nine  and  three-tenths  per  cent.  They  consider  that  gon- 
orrhea occurring  in  the  mother  in  the  later  months  of  pregnancy  is  the  cause 
of  a  large  number  of  premature  births. 

In  places  other  than  the  genital  organs  and  their  neighborhood,  the  gono- 
coccus has  been  found  in  the  pus  of  inflamed  joints  by  Stern  and  Jacquet; 
in  the  pus  of  an  inflamed  tendon  sheath  by  Kronig ;  and  in  the  mucous 
membranes  of  the  oral  cavity,  nose,  middle  ear,  and  the  conjunctiva 
of  the  new  born  by  Dohrn,  Rosinski,  Von  Leyden,  Kronig,  and  others.  The 
gonococcus  has  been  isolated  also  from  a  thrombus  of  the  pulmonary 
valve  in  a  case  of  ulcerative  endocarditis  by  Lenhartz,  and  in  the 
blood  current  by  Amann,  linger,  Yon  Leyden,  and  Michaelis.  Amann 
proved  the  identity  of  the   gonococcus   by  stain  and  culture,  and,  by  experi- 


GONOTOXINE.  i379 

mental  inoculation  of  the  human  urethra  produced  a  typical  attack  of  gonor- 
rhea complicated  by  inflammation  of  tendon  sheaths. 

The  gonococcus  may  he  cultivated  outside  the  body  by  using  as  a  culture 
medium  human  serum  in  the  form  of  hydrocele,  ovarian,  or  ascitic 
fluid  together  with  agar,  and  may  be  kept  alive  for  several  generations.  It 
is  to  be  noted  that  it  grows  only  in  neutral  or  alkaline  media.  Therefore  the 
normal  vaginal  secretion  made  acid  by  the  lactic  acid  bacterium  of  Doder- 
lein  is  hostile  to  its  growth. 

Gronotoxine. — De  Christmas  (Ann.  de  Vinstitut  Pasteur,  1900,  p.  331)  found 
that  there  is  a  toxic  product  of  the  gonoccoccus  developed  after  the  cultured  or- 
ganism is  dead,  and  that  this  is  capable  of  producing  suppuration  when  injected 
into  the  eye  of  a  rabbit.  His  work  was  confirmatory  of  the  investigations  of  Was- 
sermann  (Berl.  Min.  WochenscJir.,  1897,  ISTo.  32,  p.  685)  and  Maslovski  (Ann. 
de  gyn.  et  d'ohst.,  1899,  vol.  2,  p.  483),  who  experimented  with  pure  cultures 
of  the  gonococcus  in  nutrient  media  to  which,  after  the  cocci  had  attained 
their  full  growth,  alcohol  was  added  to  destroy  them  and  to  precipitate  the 
albumen.  The  dead  cocci  with  the  albumen  were  then  filtered  out  of  the  fluid, 
mixed  with  sterile  water,  the  alcohol  driven  off  by  heat,  and  the  fluid  so  obtained 
used  to  inoculate  rabbits  and  guinea-pigs.  The  injections  were  found  to  be 
exceedingly  j)oisonous  and  produced  both  local  inflammations  and  pyrexia 
typical  of  gonorrhea.  The  filtrate,  when  injected  into  the  animals,  had  no  effect, 
showing  that  the  poisonous  properties  were  in  the  dead  cocci.  Maslovski 
considered  that  when  the  gonococci  die,  a  gonotoxine  is  developed  in 
the  body  of  the  cocci,  an  endotoxine.  It  is  to  this  toxine  that  the  symptoms 
of  gonorrhea  are  due  rather  than  to  the  development  of  the  gonococci  in  the 
organism.  He  found  the  toxine  to  have  both  a  local  action,  inflammatory  and 
suppurative ;  and  a  general  action,  elevation  of  temperature,  loss  of  weight,  etc. 
Repeated  injections  of  the  gonotoxine  produced  no  immunity,  neither  did 
injections  of  the  pure  cultures ;  therefore  there  is  no  immunity  in  gonorrhea, 
and  reinfection  may  take  place  in  the  same  individual  an  indefinite  number  of 
times.  This  coincides  with  the  clinical  observations  of  the  disease  in  man. 
According  to  the  most  recent  and  approved  views  mixed  infection  is  not 
often  present  in  gonorrhea.  In  other  words  the  gonococcus  generally  has 
the  field  to  himself.  By  the  destruction  of  the  surface  epithelium  as  a  result  of 
gonococcus  inflammation  the  conditions  are  made  favorable  for  the  invasion  into 
the  tissues  of  the  stajDhylococcus,  streptococcus  and  colon  bacillus, 
which  are  frequently  found  after  the  gonococcus  inflammation  may  be  said  to 
be  at  an  end.  It  is  likely  that  some,  at  least,  of  the  manifestations  of  the  later 
stages  of  gonococcus  infection  are  due  to  the  formation  of  the  gonotoxine 
and  not  to  the  invasion  of  other  organisms.  Taking  advantage  of  the  discovery 
of  the  gonotoxine,  some  attempts  have  been  made  to  treat  gonococcus  in- 
fection by  the  injection  of  antigonococcus  serum  (J.  C.  Torrey,  Jour. 
Amer.  Med.  Assoc,  vol.  46,  p.  261,  also  J.  Eogers,  ibid.,  p.  263),  but  so  far 
the  results  are  not  convincing. 


380  Goisrococcus  infection. 

Curability  of  Gonococcus  Infection. — Jullien  {Rev.  iniernat.  de  med.  et  de 
cliir.,  Paris,  1905,  vol.  16)  discusses  the  curability  of  gonorrhea,  adopt- 
ing Wertheim's  view  that  in  chronic  gonorrhea  a  fresh  attack  may  be  lighted 
up  by  a  new  culture  ground.  There  is  no  real  immunity,  that  is  to  say,  if  a 
man  having  chronic  gleet,  marries  a  healthy  woman,  she  acquires  gonor- 
rhea from  him,  and  then  her  gonococci  are  able  to  set  up  an  acute  process 
in  the  husband's  urethra.  This  is  the  opinion  commonly  held  to-day,  but  it  is 
founded  more  on  clinical  observation  than  on  bacteriological  evidence.  The 
importance  of  a  man  being  cured  entirely  of  gonorrhea  before  he  is  married 
is  made  doubly  apparent.  Most  authorities  maintain  that  the  disease  may  be 
eradicated  by  persistent  treatment  conducted  over  a  long  period  of  time.  Every 
individual  who  has  once  had  gonorrhea  should  be  assumed  to  be  infected  until 
the  contrary  has  been  proved. 

Clinical  Course  and  Symptoms. — Acute  gonorrhea,  as  seen  in  prostitutes, 
is  characterized  by  a  chill,  rapid  pulse,  elevation  of  temperature, 
pelvic  pains,  burning  and  smarting  on  urination,  and,  in  the  course 
of  a  few  hours  by  a  leucorrhea,  at  first  mucous,  but  soon  becoming 
purulent,  the  pus  often  being  of  a  greenish  hue  and  mixed  with  blood.  The 
symptoms  begin  from  twenty-four  hours  to  eight  days  after  infection.  Excep- 
tionally, they  begin  before  twenty-four  hours  or  are  delayed  as  long  as  fourteen 
days.  The  disease  begins  most  frequently  in  the  urethra,  just  as  in  the  male. 
The  meatus  urinarius,  as  I  have  already  pointed  out  ("  Twentieth  Cen- 
tury Practice  of  Medicine,"  vol.  1,  p.  665),  is  protected  in  the  young  woman 
by  the  labia  urethrae.  In  the  beginning  of  coitus  the  glans  penis  pushes 
against  the  labia  and  separates  or  invaginates  them,  bringing  discharge  from 
the  male  meatus  directly  in  contact  with  the  mucous  membrane  of  the  female 
meatus.  The  glands  of  Skene  lie  just  in  the  edge  of  the  female  urethra; 
they  are  lined  with  columnar  epithelium,  the  favorite  habitat  of  the  gonococ- 
cus. Therefore,  it  often  happens  that  these  glands  are  infected.  Another 
favorite  seat  of  infection  is  the  glands  of  Bartholin,  on  either  side  of  the 
entrance  of  the  vagina  just  outside  the  hymen.  These  also  are  lined  with  a 
layer  of  columnar  epithelial  cells.  The  impact  of  the  penis  in  its  endeavor  to 
enter  the  vagina  causes  more  or  less  trauma  of  the  tissues  over  these  glands 
and  gonococci  laden  discharge  from  the  male  meatus  is  rubbed  into  them. 
The  vagina,  lined  with  pavement  epithelium  and  bathed  in  an  acid  secretion, 
is  infected,  although  less  commonly  than  the  urethra.  The  younger  the  patient 
the  more  apt  is  the  vaginal  mucosa  to  be  infected,  because  in  the  young,  the 
pavement  epithelium  is  softer  and  more  like  columnar  epithelium.  Hence  the 
frequency  of  gonococcus  vulvo-vaginitis   in  children. 

The  mucous  membrane  lining  the  cavity  of  the  cervix  uteri  is  thrown  into 
folds  and  has  branching  glands  lined  with  ciliated  columnar  epithelium.  This 
is  the  situation  next  most  commonly  affected.  Here  the  disease  is  prone  to 
lurk,  just  as  in  the  glands  of  Skene  and  Bartholin.  An  acute 
gonococcus    infection    generally    involves    the    urethra,     vagina     and 


VTJLVO-VAGINITIS    IN    LITTLE    GIELS.  381 

cervical  canal.  It  runs  a  course  of  six  weeks.  The  inguinal  lymphatic 
glands  which  receive  infective  material  from  the  vulva  and  lower  vagina  may 
become  inflamed  and  may  suppurate,  and  the  patient  has  a  "  bubo."  This 
complication  is  more  common  in  women  of  uncleanly  habits.  A  gonococcus 
arthritis  occurring  during  the  course  of  the  disease  is  a  frequent  compli- 
cation. 

Acute  gonorrhea  as  described,  except  among  prostitutes,  is  relatively 
rare.  The  symptoms  of  the  invasion  of  the  gonococcus  in  the  genital  organs 
of  women  are  generally  not  pronounced.  They  are  often,  a  smarting  on 
urination  and  an  increase  of  vaginal  discharge.  The  only  history 
of  infection  may  be  that  a  mucoid,  unirritating,  leucorrheal  dis- 
charge became  purulent  and  irritating,  but  even  this  sign  may  be  ab- 
sent. Perhaps  the  first  symptoms  to  lead  a  patient  to  consult  a  physician  will 
be  due  to  tubal  disease,  a  cervical  catarrh,  or  a  vulvo-vaginal 
abscess,  so  insidious  are  the  stages  of  invasion  of  this  disease.  In  the  chronic 
forms  of  gonococcus  infection  the  leucorrhea  loses  its  purulent 
character  and  is  generally  abundant.  The  symptoms  depend  on  the  organs 
chiefiy  involved,  Avhether  the  vulvo-vaginal  glands,  the  urethra  and 
Skene's  glands,  the  uterine  canal,  or  the  uterine  tubes  and  peri- 
toneum. 

Vulvo-vaginitis  in  Little  Girls. — Fluor  albus  in  children  was  first  men- 
tioned in  the  eighteenth  century,  and,  although  it  has  been  often  referred  to  in 
treatises  on  the  diseases  of  women  and  children,  its  serious  import  has  not 
received  sufficient  attention.  Sara  Welt-Kakels  {New  York  Bled.  Jour.,  1904, 
vol.  80,  p.  689)  observed  in  her  clinic  at  the  Mount  Sinai  Hospital,  E'ew  York, 
during  the  ten  years  from  1893  to  1903,  one  hundred  and  ninety  cases  of  vulvo- 
vaginitis, or  one  and  six-tenths  per  cent  of  all  the  children  treated.  The  largest 
number  occurred  in  children  between  the  ages  of  two  and  five  years  and  the 
disease  was  rare  after  the  tenth  year.  I  show  in  Figure  103  a  retouched  photo- 
graph of  a  case  of  gonorrheal  vaginitis  in  a  little  girl  eleven  years  old,  sent 
to  the  Johns  Hopkins  Hospital  wards ;  the  overflowing  secretion  as  it  pours  out 
of  the  vagina  into  the  perineum  is  characteristic.  jSTot  all  of  the  cases  were  of 
gonococcus  origin.  L.  Emmet  Holt  {New-  York  Med.  Jour.,  1905,  voL  81, 
p.  521)  reports  the  results  of  investigations  made  in  the  Babies'  Hospital  and 
other  institutions  for  children  in  New  York.  When  the  new  building  of  the 
Babies'  Hospital  was  opened  in  1902,  a  child  with  gonococcus  vaginitis 
was  inadvertently  admitted.  From  this  child,  in  spite  of  new  wards  and  the 
cleanest  of  surroundings,  eleven  fresh  cases  developed,  including  three  of 
gonococcus  arthritis.  The  rule  was  thereupon  established  to  admit  no 
female  child  without  a  microscopical  examination  of  the  vaginal  secretion.  In 
another  infants'  hospital  in  the  same  city,  where  there  was  said  to  be  no  vulvo- 
vaginitis, smears  were  made  from  the  vaginal  secretion  of  one  hundred  infants 
and  young  children,  the  cases  being  taken  in  order,  without  selection.  Twelve 
showed  a   yellow   purulent    discharge,    and   pus    and   gonococci   were 


382 


GONOCOCCrS    IXFECTIOljr. 


foimd  in  all  h\  microscopical  examination.  This  must  he  considered  a  large 
jjercentage,  as  most  authors  place  the  frequency  of  vulvo- vaginitis  as  ahout 
one  per  cent. 

!Xot    all    cases    of   vulvo-vaginitis    are    of    gonococcus    origin,    the 
cause  of  the  so-called  catarrhal  cases  being  unknown.     The   gonococcus   form 


Fig.  104. — A  Case  of  Goxorrheal  Vagixitis  ix  a  Child  Elevex  Years  Old,  Due  to  Rape.  The 
h-iglily  infectious  secretions  are  seen  pouring  out  over  the  perraeum.  (This  figure  is  made  from  a 
photograph.) 

comprises  nearly  all  those  in  which  the  discharge  is  purulent;  it  is  the  most 
severe  and  most  rebellious  to  treatment  besides  being  the  most  common.  Al- 
though the  inflammatory  symptoms  disappear  at  the  end  of  four  to  sis  weeks, 
exacerbations  occur.  One  author  reports  finding  gonococci  in  the  discharges 
after  the  disease  had  lasted  four  years.  Gonococcus  vulvo-vaginitis  in 
children  is  contracted  sometimes  through  sleeping  with  the  mother,  sister,  or 
other  female  relative ;  as  a  rule,  the  infection  is  indirect  and  accidental,  being 
transmitted  on  contaminated  bed  linen,  towels,  sponges,  or  even  by  bathing  in 
the  same  bath  tub.  A  marked  instance  of  the  last  mode  of  contagion  was  an 
epidemic  of  vulvo-vaginitis  which  occurred  in  the  city  of  Posen,  Germany, 
in  1S90  (ref.  to  by  AYelt-Kakels,  he.  cit.),  in  which  two  himdred  and  thirty- 
six  school  girls,  aged  from  six  to  fourteen  years,  were  taken  ill  inside  of 
eight  to  fourteen  days  with  vulvo-vaginitis.  They  had  all  used  the  same 
public  bath  house,  where,  on  account  of  limited  accommodations,  two  or  more 
children  were  required  to  bathe  in  one  tub. 


VULVO-VAGINITIS    IN    LITTLE    GIRLS. 


383 


The  statistics  of  venereal  disease  in  children  in  my  own  clinic  at  the  Women's 
Venereal  Department  of  the  Johns  Hopkins  Hospital  Dispensary,  under  the 
charge  of  Dr.  Flora  Pollack,  are  as  follows :  In  a  series  of  one  thousand  three 
hundred  and  sixty-six  patients,  one  hundred  and  thirty-nine,  or  ten  and  twenty- 
one  per  cent,  were  children  under  fifteen  years  of  age ;  and  of  these,  only  three 
cases  were  congenital.  Of  the  one  hundred  and  thirty-nine  children,  ninety- 
five,  or  sixty-eight  and  three-tenths  per  cent,  who  were  not  over  ten  years 
of  age,  were  suffering  from  acquired  infection.  In  a  number  of  cases  this 
infection  is  intentional,  being  due  to  a  superstition,  prevalent  among  the 
lower  classes,  that  the  disease  can  be  gotten  rid  of,  if  it  is  transferred  to  a 
healthy  person,  preferably  a  virgin. 

The  different  forms  of  venereal  disease  were  distributed  as  follows: 
Gonorrhea,  one  hundred  and  thirteen  cases,  or  eighty-one  and  forty-one  hun- 
dredths per  cent;  syphilis  with  gonorrhea,  fourteen  cases,  or  ten  per 
cent;  and  syphilis  alone,  twelve  cases,  or  eight  and  sixty-two  hundredths 
per  cent. 

The  accompanying  chart  (see  Fig.  104)  shows  the  ages  at  which  gonorrheal 
infection  is  most  frequently  observed  in  the  child.     It  will  be  seen  that  a  large 


No..  Cases 

Age 
IK 

Age 
2K 

Age 
3 

Age 
4 

Age 
5 

Age 

6 

Age 

1 

Age 
8 

Age 
9 

Age 
10 

Age 
11 

Age 
12 

Age 
13 

Age 
14 

Age 
15 

18 

K 

17 

f\ 

r 

16 

J 

M 

15 

A 

/ 

1 

14 

A 

/ 

/ 

13 

/  \ 

/ 

/ 

13 

1 

'    ^ 

I 

1 

A 

/ 

11 

/ 

\    / 

A 

/ 

10 

/ 

v 

/\ 

/ 

9 

/ 

Y 

/  ^ 

L 

/ 

8 

/ 

,A, 

/ 

\ 

/ 

7 

/ 

/\ 

/ 

\ 

/ 

6 

/ 

/ 

\/ 

\ 

/ 

5 

/ 

y 

V 

\ 

/ 

4 

I 

\ 

V   / 

3 

\/ 

2 

Y 

Ik 

I 

Fig.  105. — Chart  Showing  the  Ages  at  which  Gonorrhea  is  Most  Frequently  Found  between 
Eighteen  Months  and  Fifteen  Years.  It  will  be  seen  that  by  far  the  largest  number  of  cases 
occurs  before  ten  years  of  age. 


proportion  of  the  cases  (nearly  seven  per  cent)  are  not  over  ten  years  old,  a 
fact  agreeing  with  the  'statistics  of  Welt-Kakels  ( loc.  cit. )  ;  and  there  is  every 
reason  to  believe  that  the  infection  in  these  children  is  not  only  acquired,  but 
acquired  through  the  intention  of  the  other  patty,  actuated  by  the  superstition 
just  mentioned.  i  ^ 


384  Goxococcrs  iicfectiox. 

There  are  grounds  for  the  belief  that  adhesions  of  the  labia  and 
prepuce,  occlusion  of  the  hymen  and  haniatocolpos,  deformed 
uteri,  and  diseased  uterine  tubes  are  the  sequela?  of  this  disease.  The 
complications  are  acute  purulent  peritonitis,  arthritis  and  ophthal- 
mia. 

Latent  Gonorrhea. — Latent  gonorrhea  has  been  referred  to  (see  page  375). 
It  explains  why  the  gono coccus,  even  after  years  of  apparent  cure,  may 
regain  its  full  virulence.  This  brings  up  the  question  of  the  advisability  of 
marriage  in  persons  who  have  had   gonorrhea. 

Gonorrhea  and  Marriage.  — In  the  case  of  the  male  it  is  the  custom  for  genito- 
urinary specialists  to  advise  that  marriage  is  permissible  when  there  are  no 
shreds  in  the  urine,  when  the  gleety  discharge  from  the  urethra  has  ceased, 
and  when  repeated  examinations,  made  several  days  apart,  show  no  gonococci 
in  smears  made  from  mucus  from  the  meatus.  There  are  cases  on  record,  how- 
ever, where  these  precautions  have  been  observed  and  yet  a  gonorrheal 
process  has  been  set  up  in  the  previously  healthy  wife.  Other  instances  are 
numerous,  where  no  disease  was  noted  in  the  wife  until  the  husband  became 
reinfected  by  intercourse  with  a  prostitute.  It  would  seem  as  if  reinfection 
was  at  the  root  of  the  trouble  and  would  explain  many  of  the  otherwise  inex- 
plicable cases  of  gonococcus  infection.  In  the  case  of  women,  repeated  exam- 
inations of  mucus  from  the  meatus  urethree,  after  expression  of  the  urethra, 
Bartholin's  glands,  and  the  canal  of  the  cervix  uteri,  found  to  be  free  from 
gonococci,  prove  that  the  disease  is  cured.  It  is  to  be  remembered  that 
clinical  evidence  shows  that  the  disease  is  more  easily  transmissible  by  a 
previously  infected  woman  at  or  about  the  time  of  menstruation.  This  fact  is 
explained  by  the  congestion  of  the  genital  organs  always  present  at  this  time, 
with  the  consequent  liberation  from  the  tissues  of  more  abundant  flora  of 
gonococci.  Something  may  be  due  to  a  diminished  acidity  of  the  vaginal 
secretion,  which  is  ordinarily  destructive  to  the  gonococcus.  Examinations  for 
the  gonococcus  should  be  made,  if  possible,  near  a  menstrual  period. 

Instances  will  occur  to  the  mind  of  every  practitioner  of  large  experience, 
where  a  man  who  has  had  gonorrhea  has  had  subsequently  a  family  of 
healthy  children;  but  this  must  be  considered  the  excejDtion,  the  rule  being  that 
such  a  man's  wife  is  sterile,  or  has  only  one  child,  and  that  she  suffers  in  the 
future  from  uterine  disease.  Prostitutes  are  notoriously  sterile.  The  sterility 
is  supposed  to  be  due  to  gonococcus  endometritis,  to  destruction  of 
the  ciliated  columnar  epithelium  of  the  uterine  tubes  by  gono- 
coccus inflammation  or  to  closure  of  their  calibre  from  the  same 
cause.  Be  that  as  it  may,  there  can  be  no  doubt  that  gonococcus  infection 
is    one    of    the    most    frequent    causes    of    sterility    in    women. 

Diagnosis.' — In  the  acute  form  of  gonococcus  infection  the  diag- 
nosis is  not  difficult.  It  is  established  by  a  history  of  suspicious  intercourse, 
followed  in  a  day  to  a  week  by  the  symptoms  enumerated  on  page  380  and  the 
finding  of  the  gonococcus   in  the  pus  of  the  discharges. 


DIAGNOSIS.  385 

In  the  sub-acute  and  the  chronic  forms  the  diagnosis  is  hard  to 
make.  It  rests  on  a  history  of  an  unclean  coitus;  on  the  history  of  frequent 
and  painful  micturition  (an  acute  urethritis  being  strong  presumptive 
evidence  of  gonorrhea).  It  is  not  an  uncommon  experience  to  have  the 
patient  tell  her  physician  that  a  little  while  after  marriage  she  noticed  that 
she  had  a  leucorrhea  which  stained  her  linen  and  that  her  water  smarted 
when  she  passed  it.  Questioning  the  husband  at  some  subsequent  time  it  is 
learned  that  he  has  had  gonorrhea.  Great  tact  should  be  exercised  by  the 
physician  not  to  push  his  inquiries  with  the  wife  too  far,  because  of  the  danger 
of  causing  marital  troubles  that  no  doctor  can  cure.  In  gonococcus  infection 
of  the  innocent,  by  far  the  most  common  variety  of  the  disease,  it  is  seldom 
advisable  to  inform  the  woman  of  the  exact  nature  of  the  disease  she  has  ac- 
quired. It  will  never  be  done  away  with  by  too  great  frankness  on  the  part 
of  the  physician.  More  is  to  be  expected  from  missionary  work  with  men,  who 
should  appreciate  the  dangers  they  run  and  the  risks  to  which  they  are  subjecting 
those  nearest  and  dearest  to  them.  Occasionally  a  patient  will  describe  having 
had  an  adenitis  in  the  groin  or  arthritis,  but  this  is  rare.  The  pres- 
ence of  the  ''maculae  gonorrhoicae  "  of  Sanger  {Centrhl.  f.  Gyn.,  1896, 
p.  1073)  is  presumptive  evidence  of  gonorrhea.  These  consist  of  a  redness 
and  puffiness,  similar  to  the  wheal  caused  by  a  flea-bite,  at  the  orifices  of 
Skene's  glands  and  Bartholin's  glands.  The  redness  persists  long 
after  all  active  suppuration  has  ceased. 

In  examining  a  woman  for  chronic  gonococcus  infection  it  is  im- 
portant that  she  should  come. to  the  examination  without  previous  douching  or 
cleansing  of  the  genitals.  She  is  to  be  examined  in  the  dorsal  position,  on  a 
hard  surface,  and  in  a  good  light.  The  labia  are  separated  and  the  discharge 
removed  gently  with  pledgets  of  absorbent  cotton.  Smears  are  made  from  the 
pus  expressed  from  the  orifice  of  a  gland  of  Bartholin.  The  physician's 
forefinger  is  inserted  into  the  vagina,  making  backward  pressure  on  the 
perineum  to  gain  room  and  to  avoid  pressure  on  the  urethra.  Then  the  urethra 
is  stroked  with  the  forefinger  from  above  downward,  and  any  secretion  which 
may  be  present  is  expressed,  gathered  at  the  meatus  on  a  sterile  probe  or  ap- 
plicator, and  transferred  to  a  cover  glass.  The  orifices  of  Skene's  glands  are 
carefully  scrutinized  for  the  presence  of  surrounding  redness  and  pus.  A 
speculum  is  introduced  into  the  vagina,  and  with  the  aid  of  a  sterile  applicator 
a  smear  is  made  from  the  discharge  from  the  cervical  canal. 

The  detection  of  the  gonococcus  by  staining  and  Gram  decolorizing  in 
the  discharges  is  proof  positive  of  the  disease.  Some  authors  (Calmann,  Klein, 
and  Fritsch)  have  insisted  on  the  necessity  of  making  cultures  of  the  gonococ- 
cus. On  account  of  the  great  difficulties  surrounding  the  growing  of  this  bac- 
terium outside  the  tissues  of  the  human  body  this  is  seldom  done  in  practice, 
although  it  may  furnish  valuable  confirmatory  evidence.  Finding  the  gono- 
coccus in  bits  of  tissue  removed  at  the  time  of  operations  on  the  genitalia  is 
proof  of  the  nature  of  the  diseased  condition.  Too  often  the  diagnosis  of 
26 


386  GONOCOCCUS    INFECTION, 

chronic    gonococciis    infection    must  be  only  a  probable  one,  because  of 
the  difficulty  in  finding  the   gonococcus. 

Treatment. — In  acute  gonococcus  infection  rest  in  bed  and 
scrupulous  cleanliness  are  to  be  enjoined.  It  is  not  sufficient  to  tell  the 
patient  to  be  clean ;  exact  instructions  must  be  given  as  to  the  details.  A  sterile 
pad  or  soft  cloth  fresh  from  the  laundry  should  be  worn  constantly  over  the 
vulval  region.  When  it  is  wet  with  discharge,  it  is  to  be  burned  and  a  new 
one  applied.  The  genitals  are  to  be  bathed  at  least  three  times  a  day  with 
warm  half  per  cent  boric  acid  solution,  and  oftener,  if  the  discharge  is  pro- 
fuse. The  very  great  danger  of  carrying  infection  on  the  fingers  to  other  per- 
sons or  to  other  mucous  membranes  of  the  same  person  should  be  pointed  out. 
By  this  means  it  is  possible  to  avoid  gonococcus  ophthalmia,  a  serious 
and  destructive  disease,  especially  in  adults;  and  gonococcus  vulvo- 
vaginitis in  children,  to  say  nothing  of  gonococcus  proctitis.  Huber 
(ref.  to  in  Centrhl.  f.  Gyn.,  1889,  p.  1508)  found  rectal  gonorrhea  in 
twenty-four  and  a  half  per  cent  of  three  hundred  and  eighteen  prostitutes  who 
had  gonorrhea.  It  is  important  that  the  natural  barrier  of  the  sphincter  ani 
should  not  be  passed  by  a  syringe  nozzle  or  the  examining  finger  during  an 
attack  of  acute  gonococcus  infection.  Because  of  the  likelihood  of 
spreading  the  infective  material  to  neighboring  organs  it  is  unwise  to  use  any 
further  local  treatment.  It  has  happened  only  too  frequently  that  gonococci 
of  the  cervical  canal  have  been  carried  beyond  nature's  barrier,  the  internal 
OS  uteri,  by  the  physician's  sound,  with  resulting  endometritis  and  sal- 
pingitis. So  also  the  passing  of  a  catheter  during  the  acute  stage  of 
gonococcus  infection  is  very  likely  to  be  followed  by  infection  of  the  blad- 
der. Coitus  must  be  forbidden  and  the  husband  is  to  be  kept  under  observation, 
if  possible.  The  diet  should  be  bland  and  free  from  spices  and  stimulants  of 
all  kinds ;  a  milk  diet  is  valuable.  Large  quantities  of  water  should  be  taken 
to  dilute  the  urine  and  wash  away  the  gonococci,  and  the  bowels  should  be 
moved  daily  with  saline  purgatives.  Bromide,  hyoscyamus,  and  opium 
in  special  cases  are  indicated  to  relieve  pain  and  restlessness.  A  useful  pre- 
scription to  relieve  painful  urination  is : 

^  Potassii  acetatis oj 

Tinct.  hyoscyami oj 

Aquae oiij 

S.     One  teaspoonful  in  a  third  of  a  tumbler  of  water  every 
three  hours. 


Also: 


I^   Copaibas oiv 

Spts.  eth.  nitrosi ovj 

Syr.  simp oij 

S.     One  teaspoonful  in  a  wineglass  of  water  every  two  hours. 


TREATMENT.  387 

In  the  sub-acute  and  chronic  stages  of  the  disease  the  object  of 
treatment  is  the  destruction  of  the  gonococcus  together  with  the  superficial 
layers  of  epithelium.  It  is  important  that  the  treatment  should  be  thorough, 
and  no  nooks  and  corners  overlooked.  The  patient  is  placed  in  Sims'  position 
and  a  small  Sims'  speculum  introduced.  The  Sims'  speculum  is  better  for  this 
purpose  than  other  specula  because  it  covers  a  minimum  surface  of  the  vagina. 
In  the  Sims'  position  the  folds  of  the  vagina  are  eliminated  to  a  large  extent 
by  atmospheric  dilatation,  and  thus  all  portions  of  it  may  be  brought  into  con- 
tact v^^ith  the  remedial  agent. 

The  vagina  and  vulva  are  wiped  thoroughly,  first  with  successive  pledgets 
of  absorbent  cotton  held  in  uterine  dressing  forceps  and  dipped  in  warm  water, 
and  then  with  dry  cotton.  The  canal  of  the  cervix  is  swabbed  several  times 
with  cotton-wound  uterine  applicators,  dipped  into  a  ten  per  cent  solution  of 
silver  nitrate.  Unless  there  is  positive  evidence  that  the  infection  has 
reached  the  uterine  cavity  proper,  the  tip  of  the  applicators  should  not  be  passed 
through  the  internal  os  uteri.  By  steadying  the  cervix  with  a  tenaculum,  the 
treatment  of  the  cervical  canal  can  be  accomplished  in  most  cases  without 
dilatation  of  the  external  os.  l^ow  and  then  slight  dilatation  with  the  Hanks' 
dilators  will  be  necessary.  The  entire  vagina  is  treated  in  the  same  way  with 
pledgets  of  absorbent  cotton  soaked  in  silver  solution  until  every  fold  and  de- 
pression has  been  touched,  the  speculum  being  withdrawn  as  the  posterior  wall 
is  painted  from  above  down.  The  excess  of  silver  solution  is  removed  with  dry 
absorbent  cotton.  The  speculum  is  then  lubricated  and  reintroduced  into  the 
puckered  and  whitened  vagina,  after  which  the  entire  cavity  is  given  a  copious 
smearing  of  vaselin,  and  two  packings  of  non-absorbent  cotton  with  strings  at- 
tached are  left  in  the  vagina.  Thus  the  danger  of  adhesion  of  the  folds  is 
obviated  and  the  patient's  comfort  promoted.  The  packings  are  to  be  removed 
at  the  end  of  forty-eight  hours. 

The  patient  is  now  placed  in  the  dorsal  position.  Unless  there  is  evidence 
that  the  urethra  has  not  become  infected,  a  small  Kelly  endoscope  (l^o.  8  or 
9)  is  passed  up  to  the  neck  of  the  bladder,  but  not  into  it.  The  urethra 
is  then  swabbed  with  cotton-wound  uterine  applicators,  soaked  in  a  five  per 
cent  solution  of  silver  nitrate,  the  urethra  being  intolerant  of  a  stronger 
solution  except  under  anesthesia.  As  the  reddened  wall  of  the  urethra  rolls 
into  the  lumen  of  the  cystoscope  during  its  withdrawal,  it  is  touched  with  the 
tip  of  the  applicator.  It  is  well  to  have  at  least  two  applicators  ready  for  use 
and  dipped  in  the  silver  solution  before  beginning  the  treatment,  for  economy 
of  time  is  of  value.  The  pain  may  be  lessened  in  particularly  sensitive  patients 
by  first  inserting  in  the  urethra  an  applicator  with  its  cotton-soaked  solution 
of  cocain  hydrochlorate  (ten  per  cent).  By  holding  the  thumb  against 
the  shaft  of  the  applicator  the  applicator  may  be  withdrawn  and  the  cotton  left 
in  the  urethra.  After  five  minutes  the  swabbing  of  the  urethra  with  nitrate 
solution  may  be  proceeded  with.  After  the  cystoscope  is  out  of  the  urethra 
the   orifices    of    Skene's    glands    receive    special    attention,    so    also   the 


388 


GONOCOCCUS    INFECTION. 


orifices  of  Bartholiu's  glands.  In  tlic  chronic  cases  where  Skene's 
glands  are  the  seat  of  chronic  infection  they  are  to  be  injected  with  silver 
solution  by  means  of  a  large  hypodermic  syringe  needle,  fitted  into  a  two-inch 

section  of  rubber  tubing  or  a 
new  sterilized  bulb  of  a  medi- 
cine dropper.  If  the  tubing  is 
used,  the  free  end  is  closed  by 
tying  it  with  a  thread.  This 
method  of  treatment  and  the 
best  method  of  exposing  the  ori- 
fices of  Skene's  glands  with 
bent  hairpins  held  in  forceps 
has  been  described  by  me  (see 
Fig.  105).  In  obstinate  cases 
of  infection  it  is  necessary  to 
lay  open  the  glands  into  the  va- 
gina. This  is  done  under  cocain 
anesthesia,  using  the  cotton 
soaked  in  cocain  solution  as  de- 
scribed in  the  treatment  of  the 
urethra.  A  fine  probe  is  insert- 
ed to  the  full  length  of  the  gland 
(half  an  inch)  and  the  probe  is 
cut  down  on  with  a  bistoury. 
Then  the  mucous  membrane  is 
cauterized  with  nitrate  of 
silver  solution,  ten  per 
cent.  The  glands  of  Bar- 
tholin  receive  the  same  treat- 


FiG.  106. — Bext  Hairpins  Grasped  in  Artery  Forceps 
AND  Used  as  a  Speculum  to  Expose  the  Anterior 
Portion  of  the  Urethra,  More  Particularly  the; 
Orifices  of  Skene's  Glands. 


ment  as   Skene^s  glands.    If 


an  abscess  has  formed,  it  must 
be  opened  under  aseptic  precau- 
tions, and  the  interior  cauterized. 
After  all  the  points  of  infection  have  received  attention  the  vulva  is  smeared 
with  vaselin,  and  the  patient  is  instructed  to  remove  the  tampons  in  two  days 
and  report.  It  may  be  necessary  to  repeat  the  treatment  several  times,  at  inter- 
vals of  two  or  three  days.  Protargol  in  ten  per  cent  solution  may  be  sub- 
stituted for  the  nitrate  of  silver.  It  is  less  irritating  than  the  nitrate, 
and,  although  not  as  germicidal,  has  given  the  best  results  clinically  of  all  the 
many  silver  salts  wdth  the  single  exception  of  the  nitrate.  The  number  of  drugs 
recommended  for  the  treatment  of  gonococcus  infection  is  legion.  Among  them, 
leaving  out  the  silver  salts,  may  be  mentioned  Churchill's  tincture  of 
iodine,  corrosive  sublimate,  formalin,  permanganate  of  potash, 
methyl  blue,  brewer's   yeast   and  nascent  carbonic   acid   gas. 


TREATMENT    IN    LITTLE    GIRLS.  389 

If  the  vagina  remains  congested  as  a  result  of  the  cauterization  with  the 
nitrate  of  silver,  it  is  best  to  luake  several  treatments  with  tampons  soaked 
in  ichthyol  and  glycerin  (one  drachm  to  one  ounce)  before  renewing  the 
more  vigorous  treatment.  The  nitrate  of  silver  treatment  is  more  or  less 
painful,  and  in  some  patients  it  is  advisable  to  administer  a  sedative  after  em- 
ploying it.  In  cases  where  it  is  not  possible  to  follow  up  this  treatment,  as 
where  patients  cannot  be  kept  under  observation  or  are  subjected  to  reinfection, 
something  may  be  gained  by  the  use  of  vaginal  suppositories  of  boroglycerid, 
gelatin,  and  protargol,  two  per  cent.  One  or  two  of  these  suppositories, 
according  to  the  size  of  the  vagina,  are  to  be  inserted  by  the  patient  every  night 
at  bedtime  and  a  napkin  worn.  Considerable  benefit  is  obtained  often  in  chronic 
cases  by  the  daily  use  of  a  two-quart  douche  of  hot  permanganate  of  pot- 
ash solution,  1 :  1500,  or   creolin,   one  half  per  cent. 

The  Dry  Treatment. — In  rebellious  cases  nothing  is  more  efficacious 
than  the  use  of  iodoform  powder  dusted  on  dry  elastic  non-absorbent  cotton 
tampons,  so  placed  as  to  balloon  out  the  vagina  moderately,  thus  removing  the 
folds  from  its  mucous  membrane.  The  packing  should  be  done  with  the  patient 
in  the  Sims'  or  the  knee-breast  position  and  repeated  every  third  day,  the  patient 
removing  the  tampons  on  the  night  of  the  second  day  and  taking  a  douche  of 
permanganate    of   potash,    1:1500. 

Treatment  of  Gonococcus  Vulvo-vaginitis  in  Little  Girls. — The  mother  is  to  be 
informed  of  the  infectious  nature  of  the  disease  and  charged  with  the  im- 
portance of  carrying  out  the  treatment  with  the  greatest  care.  Strict  attention 
is  to  be  paid  to  cleanliness,  and  all  cloths  used  about  the  child  are  to  be  burned 
after  use.  The  mother  or  nurse  is  to  prepare  a  warm  solution  of  perman- 
ganate of  potassium,  1:  2000,  and  place  the  child  on  her  back  on  a  table 
or  other  hard  surface  in  a  good  light.  The  thighs  are  to  be  flexed  and  the  hips 
placed  on  a  rubber  cloth  or  Kelly  pad  draped  into  a  pail  on  the  floor.  The 
labia  majora  are  separated  and  the  discharge  washed  away  from  the  vulva  by 
gentle  sopping  with  a  pledget  of  absorbent  cotton.  The  vagina  is  irrigated 
with  a  soft-rubber  catheter  attached  to  a  syringe  (either  bulb  or  fountain  syringe 
will  serve).  The  frequency  of  the  irrigations  is  timed  according  to  the  amount 
of  the  discharge ;  if  it  is  very  profuse,  two  or  three  times  a  day,  if  less,  once  a 
day  will  be  suflfieient.  In  the  chronic  stages  of  the  disease  a  solution  of 
nitrate  of  silver,  1 :  500,  may  be  substituted  for  the  permanganate  of 
potash  solution;  often,  it  is  a  good  plan  to  alternate  the  two.  A  sterile 
pad  held  in  place  by  a  T  bandage  prevents  the  spread  of  infection. 

An  excellent  posture  in  which  to  treat  a  child  is  the  knee-breast  position,  as 
shown  in  Figure  106.  The  nurse  should  first  place  a  pledget  of  cotton  saturated 
with  a  ten  per  cent  solution  of  coca  in  against  the  hymen ;  and  after  ten  minutes 
the  child  is  placed  in  the  knee-breast  position  and  a  Kelly  speculum  (ISTo.  10) 
is  introduced.  This  can  l)e  done  without  rupture  of  the  hymen.  The  vagina 
then  balloons  out  so  that  all  parts  are  exposed  to  view,  and  can  be  easily  treated 
with  a  three  to  thirty  per  cent  solution  of  silver  nitrate  (see  Eig.  107).     This 


Fig.  107. — Examination  of  a  Little  Child  with  Gonorrheal  Infection  of  the  Vagina.  The 
figure  shows  well  the  relative  size  of  the  body  of  the  child  compared  with  the  instrument  and  the 
hands  of  the  examiner.  The  speculum,  which  is  only  1  cm.  in  diameter,  can  be  introduced  without 
injury  to  the  hymen.  In  the  knee-breast  position  the  vagina  distends  to  a  maximum  wdth  air  and 
can  be  easily  treated,  as  shown  in  the  next  figure. 


Fk;.  108. — Showing  a  Speculum,  1  cm.  in  Diameter,  Introduced  into  the  Vagina  of  a  Child. 
A  treatment  of  nitrate  of  silver  from  10  to  30  per  cent  is  thoroughly  applied  to  all  parts  of  the  vaginal 
wall. 

390 


TREATMENT    IN    LITTLE    GIELS.  391 

treatment  is  not  painful  or  alarming,  but  it  is  necessary,  of  course,  to  gain  the 
confidence  of  the  child  before  applying  it.  If  the  urethra  is  also  involved,  a 
five  per  cent  solution  of  nitrate  of  silver  is  injected  by  means  of  small  glass 
syringes,  either  into  the  meatus  urinarius  or  over  the  entire  vestibule,  if  the 
child  will  not  keep  quiet.  Chafing  is  best  relieved  by  inunctions  of  zinc  oint- 
ment, unless  the  case  is  complicated  by  syphilis,  when  the  parts  must  be  kept 
dry;  for  this  purpose  a  dusting  powder  of  equal  parts  of  calomel,  bismuth 
subnitrate,  and  boric  acid  is  best.  Constitutional  treatment  must  be 
added,  selected  in  accordance  with  the  child's  age.  No  home  applications  are 
advised,  other  than  cleanliness  of  the  parts  and  the  use  of  the  ointment  or  pow- 
der just  mentioned,  as  the  mother  cannot  be  trusted  to  carry  them  out.  The 
child  must  return  for  treatment,  at  first  on  alternate  days,  and  afterwards  with 
lengthening  intervals  as  the  case  improves. 

The  complications  of  gonococcus  infection,  such  as  stricture 
of  the  urethra,  cystitis,  proctitis,  ophthalmia,  suppurative 
adenitis  and   arthritis,   should  be  given  appropriate  treatment. 

Whatever  the  treatment  employed,  it  should  be  persisted  in  until  the  dis- 
charges are  free  from  gonococci.  The  poor,  half -cured  victims  of  gonococcus 
infection  are  a  menace  to  the  community  and  a  stain  on  the  fair  name  of  the 
medical  profession. 


CHAPTEK    XVII. 
SYPHILIS. 

Definition,  p.  392.     Causal  agent,  p.  392.     Evolutionary  modes,  p.  393.     Variations  in  type,  p. 

395.     Irregular  sjiahilis,  p.  396.     Parasj'philis,  p.  396.     Reinfection  in  acquired  syphilis, 

p.  397.     Reinfection  in  hereditary  syphilis,  p.  397.     Morbid  anatomy,  p.  397.     Sources 

and  modes  of  syphihtic  contagion,  p.  398. 
Primarj'  sj-phihs:  Chancre,  p.  399.     Bubo,  p.  402.     Diagnosis  of  chancre,  p.  402.     Prognosis  of 

chancre,  p.  403.     Treatment  of  chancre,  p.  404.     Wassermann  reaction,  p.  405.     Salvarsan, 

p.  408. 
Secondary  syphilis:  General  considerations,  p.  411.     Varieties,  p.  411,     Diagnosis,  p.  412. 
Tertiary  syphihs:  Vai'ieties,  p.  418.     Diagnosis,  p.  419. 
Syphilis  of:  Appendages  to  skin,  p.  420.     Alimentary  system,  p.  421.     Respiratory  system,  p. 

424.     Circulatory    system,    p.   424.     Genito-urinary    system,    p.   425.     Female  generative 

system,  p.  426.     ]\Iotor  system,  p.  427.     Eye  and  ear,  p.  428.     Nervous  system,  p.  430. 
Hereditary  syphilis,  p.  432.     Transmission  of  syphilis  to  third  generation,  p.  436. 
Treatment  of  syphilis,  p.  437. 
Sj'phihs  and  marriage,  p.  443.     Prophylaxis  through  education,  p.  449. 

Syphilis  is  a  chronic,  contagious  disease,  intermittent  in  its  manifesta- 
tions, and  indefinite  in  its  duration.  It  is  susceptible  of  being  communicated 
from  one  individual  to  another  by  inoculative  contact,  direct  or  mediate,  and 
is  transmissible  by  inheritance. 

THE    CAUSAL    AGENT    OF    SYPHILIS. 

It  has  long  been  assumed  that  syphilis  belonged  to  the  class  of  microbian 
diseases,  from  analogies  in  its  evolution  and  processes  with  other  infectious 
diseases,  the  microbian  origin  of  -^hich  has  been  demonstrated.  Many  investi- 
gators have  claimed  the  discovery  of  a  specific  organism  as  the  pathogenic 
agent  Since  the  discovery  of  the  spirocheta  pallida  or  treponema 
pallidum  by  Schaudinn  and  Hoffmann,  in  1905,  and  the  demonstration  of 
its  presence  in  the  blood  and  lesions  of  syphilitics,  it  has  been  generally  recog- 
nized as  the  specific  germ  of  syphilis.  At  the  present  time,  the  etiological 
views  of  Klebs,  Lustgarten,  Van  Xiessen,  Jullien  and  de  Lisle,  Max  Joseph 
and  PiorkoTvski  have  only  a  historical  interest.  The  spirocheta  pallida  is 
a  spiral  organism,  having  the  form  of  a  corkscrew.  The  filament  is  a  quarter 
to  one  micro-millimetre  thick  and  four  to  twelve  micro-millimetres  long.  The 
spirals  are  steep,  the  ends  being  sharp,  and  often  having  long  thread  flagella. 
The  average  number  of  spirals  is  from  eight  to  twelve,  but  sometimes  there 
are  more.  Giemsa  proposed  a  special  stain  for  the  spirochete,  and  lately, 
April,  1907,  he  modified  the  stain,  in  such  a  manner  that  the  organism  can 
be  demonstrated  in  smears  in  a  few  minutes. 

The  spirocheta  pallida  has  been  demonstrated  in  smears  from  prac- 
392 


THE    EVOLUTIONAEY    MODE    OF    SYPHILIS.  393 

ticallj  all  the  manifestations  of  early  syphilis,  as  chancre,  papule,  mucous 
patches,  scaly  patches,  as  well  as  in  the  blood,  before,  during  and  after  the 
appearance  of  the  early  manifestations.  In  hereditary  syphilis  the  spiro- 
chetae  have  been  demonstrated  as  abundantly  present  in  the  fetus,  in  the  pla- 
centa, and  in  sections  from  the  internal  organs,  especially  after  the  publication 
of  Levaditti's  method. 

The  spirocheta  pallida  is  also  found  in  smears  from  syphilitic  lesions 
of  inoculated  apes.  A  doubt  exists,  however,  as  to  the  identity  of  the  structure 
found  in  tissues  with  the  real  spirochete  found  in  smears.  It  is  claimed 
that  the  structure  considered  in  tissues  as  a  sjDirocheta  pallida  cannot  be 
difPerentiated  from  other  spirochetse  and  from  various  tissue  elements.  While 
the  sj)irocheta  pallida  has  been  generally  accepted  as  the  germ  produc- 
ing syphilis,  yet  the  rigorous  conditions  demanded  by  modern  science  as  essen- 
tial to  the  acceptance  of  the  view  that  a  specific  micro-organism  is  the  cause 
of  an  infectious  disease,  have  not,  in  its  case,  been  complied  with. 

These  conditions  are,  first,  that  the  specific  organism  should  be  found  in 
the  diseased  tissues,  and  in  the  products  of  no  other  disease.  Second,  that  the 
organism  should  be  susceptible  of  cultivation  outside  the  human  body.  Third, 
that  when  a  product  of  pure  cultures  is  introduced  into  the  same  species  from 
which  it  was  derived,  it  should  produce  an  identical  disease.  Up  to  the  present 
time,  no  culture  has  been  made  of  this  organism,  and  the  scientific  proof  of 
its  pathogenic  role  has  not  been  absolutely  demonstrated.  Yet  the  constant 
presence  of  the  organism  in  the  lesions  of  both  acquired  and  hereditary 
syphilis,  would  seem  to  afford  the  strongest  presumptive  proof  of  its  being  the 
causative  agent.  In  addition,  the  prompt  disappearance  of  spirochetae 
from  the  tissues  after  the  use  of  mercury,  has  been  frequently  observed.  In 
the  present  state  of  our  knowledge,  then,  we  may  conclude  that  the  spirocheta 
pallida   is  probably  the  pathogenic  agent  of  syphilis. 

THE    EVOLUTIONARY    MODE    OF    SYPHILIS. 

Syphilis  is  characterized  by  a  certain  definite  order  or  regiilarity  in  its 
evolutionary  course  which,  though  not  absolutely  constant,  is  yet  sufficiently 
uniform  to  admit  of  its  division  into  three  periods  or  stages,  classified  as  the 
primary,    secondary,    and    tertiary    stages. 

When  the  virus  is  introduced  into  the  organism,  there  is  no  appreciable 
evidence  of  its  action  during  a  period  of  three  to  four  weeks,  on  an  average  of 
twenty-six  days;  this  has  been  termed  the  period  of  primary  incuba- 
tion. There  then  appears  at  the  point  of  inoculation  a  circumscribed  infil- 
tration, termed  the  initial  lesion  or  chancre,  which  for  a  time  consti- 
tutes the  sole  sign  of  the  disease.  It  is  probable  that  the  chancre  serves  as  a 
focus  for  the  multiplication  of  the  infectious  elements,  from  which  they  are 
diffused  into  the  system  through  the  medium  of  the  lymph  and  blood  channels. 

The  interval  between  the  presence  of  the  chancre  and  the  appearance  of 


394  SYPHILIS. 

visible  manifestations  of  tlie  disease  upon  the  surface  of  the  body,  is  termed 
the  period  of  secondary  incubation,  "U'hich  averages  from  six  to  eight 
weeks  in  duration.  During  the  period  of  secondary  incubation,  there  is  an 
enlargement  and  induration  of  the  nearest  lymph  glands  and  sometimes  of  the 
lymphatic  channels  leading  thereto,  with  the  development  of  various  prodromal 
symptoms,  chiefly  of  a  subjective  character. 

Prominent  among  the  prodromal  symptoms  vrhich  precede  the  outbreak 
of  general  syphilis  is  syphilitic  fever,  vhich  may  be  accompanied  by 
headache,  pains  in  the  back  and  limbs,  and  other  signs  of  constitutional  dis- 
turbance. The  febrile  reaction  of  syphilis  has  no  Trell-defined  characters  which 
can  be  considered  as  specific.  In  many  cases  it  is  so  slight  as  to  escape  obser- 
vation. Syphilitic  fever  rarely  possesses  clinical  importance.  It  usually  sub- 
sides spontaneously  with  the  appearance  of  the  eruption.  There  are  numerous 
other  symptoms,  of  a  subjective  character,  which  may  occur  in  the  early 
stage  of  syphilis,  such  as  pains  in  the  muscles,  bones,  and  so  forth.  In  addi- 
tion to  the  rheumatoid  pains,  headache,  arthralgia,  or  osteocopic  pains  along 
the  prominent  parts  of  the  bony  skeleton,  may  mark  the  invasion  of  syphilis, 
although  the  osteocopic  pains  are  more  pronounced  at  a  later  stage.  During 
this  primary  period  there  is  an  alteration  in  the  constituents  of  the  blood, 
characterized  by  an  increase  of  the  white  corpuscles  and  albuminous  con- 
stituents, and  a  diminution  in  the  number  of  the  red  corpuscles. 

The  secondary  stage  of  syphilis  is  marked  by  an  outbreak  of  gen- 
eralized and  symmetrical  eruptions  upon  the  skin  and  mucous  membranes. 
The  eruptions  vary  in  form,  in  extent,  and  in  severity,  while  exhibiting  cer- 
tain specific  features  which  stamp  them  as  the  peculiar  product  of  syphilis. 
They  are  not  continuously  present,  but  come  out  in  successive  gTOups,  periods 
of  activity  alternating  with  periods  of  intermittence,  in  which  no  active  symp- 
toms are  present.  Exceptionally,  the  eruption  may  be  continuously  present 
during  a  prolonged  period. 

Between  the  second  and  third  stages  of  syphilis  there  is  an  intermediate 
period,  of  exceedingly  variable  duration,  in  which  the  disease  remains  latent 
or  there  are  only  occasional  manifestations.  This  cessation  of  activity  may  be 
permanent,  marking  the  definite  end  of  the  disease,  or  it  may,  after  a  more  or 
less  prolonged  period  of  latency,  be  succeeded  by  tertiary  manifestations. 

The  tertiary  stage  is  characterized  by  lesions  of  the  deeper  structures, 
the  subcutaneous  tissues,  the  muscles,  bones,  and  internal  organs.  The  tertiary 
lesions  of  syphilis  are  limited  and  localized,  rarely  symmetrical,  with  a  pro- 
gressive and  destructive  tendency,  producing  more  or  less  extensive  loss  of 
tissue.  The  duration  of  the  tertiary  stage  is  practically  indefinite.  The  dis- 
ease may  be  latent  for  months  or  years,  and  then  manifest  renewed  activity 
accompanied  by  general  symptoms,  indicating  the  revival  of  the  infective 
process. 

While  this  division  of  syphilis  into  distinct  stages  has  been  found  con- 
venient for  the  purposes  of  description,  it  is  to  be  understood  that  it  is,  to  a 


VARIATIONS    IN    THE    TYPE    OF    SYPHILIS.  395 

certain  extent,  arbitrary,  and  devoid  of  scientific  accuracy.  There  is  no 
definite  chronological  limit  which  separates  the  second  and 
third  stages  of  syphilis.  The  distinction  between  the  two  is  based 
rather  upon  the  character  of  the  pathological  process  than  upon  the  age  of 
the  diathesis.  Lesions  of  a  secondary  type  may  continue  to  recur  long 
after  the  completion  of  the  secondary  stage,  it  may  be  five  to  ten  years  later ; 
while,  exceptionally,  lesions  which  are  pathologically  of  the  tertiary  type 
may  be  developed  within  the  first  few  months  of  the  disease.  While  there  is 
no  distinct  line  of  demarcation  between  the  two  stages,  it  may  be  said  in  a 
general  way  that  secondary  eruptions  are  generalized,  symmetrical  in  develop- 
ment, superficial  in  character,  and  show  a  tendency  to  spontaneous  resolution. 
Tertiary  lesions  are  non-symmetrical,  deeper-seated,  and  do  not  exhibit 
the  same  tendency  to  spontaneous  resolution.  Instead  of  being  reabsorbed,  they 
tend  to  fibrous  organization  and  fatty  degeneration.  During  the  secondary 
stage,  the  blood  as  well  as  the  lesions  contains  the  poison  of  syphilis,  transmis- 
sible by  contagion  and  by  inheritance.  When  syphilis  has  passed  into  the 
tertiary  stage,  the  disease  was  formerly  considered  no  longer  contagious  or 
transmissible  by  inheritance,  but  since  the  discovery  of  the  spirocheta 
pallida,  and  its  demonstrated  presence  in  gummata  and  other  lesions  of  the 
tertiary  stage,  this  view  must  be  subject  to  modification. 

VARIATIONS    IN    THE    TYPE    OF    SYPHILIS. 

Syphilis  exhibits  the  widest  variations  in  the  type  of  the  disease,  as  well 
as  in  the  intensity,  the  multiplicity,  and  the  succession  of  its  manifestations, 
and  in  the  severity  and  duration  of  their  morbid  activity.  Many  cases  of 
syphilis  are  mild  throughout  their  whole  course,  their  essential  benigTiity  being 
expressed  in  the  character  of  the  surface  manifestations,  which  impress  the 
skin  so  lightly  as  to  leave  no  trace.  The  entire  manifestations  may  be  confined 
to  roseola,  a  slight  papular  eruption,  and^  possibly,  implication  of  the  hairy 
scalp,  with  slight  alopecia,  all  of  which  may  disappear  in  a  few  months,  and 
the  patient  afterwards  exhibit  no  symptoms.  In  some  cases,  mucous  patches 
in  the  mouth  constitute  the  sole  manifestation  of  the  disease.  According  to 
Fournier,  the  secondary  symptoms  may  be  so  mild  and  evanescent  as  to  entirely 
escape  the  patient's  attention. 

In  other  cases,  the  eruption  is  generalized  and  universal,  with  an  almost 
constant  succession  of  outbreaks.  Before  one  eruption  has  disappeared,  another 
is  in  process  of  development,  so  that,  in  one  form  or  another,  the  eruption  is 
almost  constantly  present.  There  is  also  a  great  diversity  shown  in  the  char- 
acter of  the  morbid  process.  In  some  cases,  the  lesions  are  dry  and  atrophic 
throughout  the  course  of  the  disease.  In  others,  the  lesions  are  moist,  with 
a  marked  tendency  to  suppuration.  The  ulcerative  form  not  infrequently 
takes  on  the  characters  of  phagedena.  In  another  type,  confined  almost  exclu- 
sively to  women,  the  surface  manifestations  may  be  slight  or  absent,  while 


396 


SYPHILIS. 


the  nervous  symptoms,  in  tlie  shape  of  neuralgic  pains,  asthenia,  hysteria,  and 
so  forth  are  pronounced,  and  constitute  the  almost  entire  symptomatology  of 
the  secondary  stage.  In  still  another  class  of  cases,  which  Fournier  has  denom- 
inated syphilis  secondare  tardive,  lesions  of  the  erythematous  or  papular  type, 
often  associated  with  mucous  patches,  may  continue  to  recur  as  late  as  the 
eleventh  or  twelfth  year  of  the  disease. 

IRREGULAR    SYPHILIS. 

A  great  many  cases  of  syphilis  are  characterized  by  an  unusual  mode  of 
evolution.  This  deviation  from  the  typical  mode  impresses  certain  peculiari- 
ties.upon  the  eruptive  phenomena,  and  renders  it  impossible  to  classify  them, 
as  there  is  an  intermingling  or  blending  of  secondary  and  tertiary  manifesta- 
tions, developed  without  order  or  regular  sequence. 

In  the  form  known  as  "benign  rapid  syphilis,"  tubercles  and  gum- 
mata  make  their  appearance  before  the  complete  disappearance  of  the  papular 
or  pustular  eruptions,  and  there  may  be  a  simultaneous  development  of  sec- 
ondary and  tertiary  lesions  during  the  entire  course  of  the  disease.  The  lesions, 
however,  are  essentially  benign. 

In  malignant,  precocious  syphilis,  the  syphilitic  process  seems  to 
skip  over  the  superficial  structures  and  to  attack  at  once  the  deep  tissues.  Inde- 
pendent of  the  precocity  of  this  process,  the  elements  of  malignancy  are  found 
in  the  violence  of  the  irruption,  the  multiplicity  of  the  lesions,  their  ulcerative 
and  rapidly  destructive  character,  and,  very  frequently,  the  presence  of  grave 
systemic  complications.  It  was  at  one  time  supposed  that  the  malignancy  of 
syphilis  was  possibly  due  to  a  greater  virulence  of  the  infectious  elements.  It 
is  now  recognized  that  syphilis  takes  on  a  more  malignant  turn  from  circum- 
stances connected  with  the  general  condition  and  nutrition  of  the  patient.  In 
other  words,  differences  in  the  type  of  syphilis  must  be  sought  for,  not  in  the 
quality  or  source  of  the  syphilitic  virus,  but  in  the  character  of  the  soil  in 
which  it  is  implanted.  Independent  of  the  constitutional  peculiarities  of  the 
patient,  which  may  constitute  an  individual  predisposition,  there  are  numer- 
ous accidental  conditions,  of  a  general  or  local  nature,  which  may  modify  the 
type  of  the  disease.  Among  these  etiological  factors  may  be  mentioned  mental 
or  bodily  overstrain;  the  use  of  alcohol;  tuberculosis,  scrofulosis,  and  other 
debilitating  conditions.  In  addition,  local  causes,  traumatisms,  various  exter- 
nal irritants,  the  use  of  tobacco,  etc.,  may  aggravate  local  eruptions. 

PARASYPHILIS. 

The  pathological  significance  of  syphilis  has  been  rendered  much  graver 
by  the  inclusion  of  a  group  of  affections  which  are  syphilitic  in  their  nature 
and  origin,  but  which  do  not  respond  to  the  effects  of  specific  treatment.  It 
is  claimed  that  these  morbid  manifestations  are  not  due  to  the  direct  action 
of  the  microbe,  but  result  from  the  action  of  the    syphilo-toxines,    which 


REINFECTION    IN    ACQUIRED    AND    IN    HEREDITARY    SYPHILIS,  397 

impress  the  tissues  in  a  manner  peculiar  to  these  products.  It  is  asserted  that 
the  syphilo-toxines  have  a  special  and  selective  action  upon  the  nerve 
tissue.  In  addition  to  functional  disorders,  such  as  neurasthenia,  hysteria, 
tabes,  general  paralysis,  epilepsy,  leucoplasia-buccalis,  and  arterio-sclerosis,  a 
large  number  of  the  dystrophies  and  degenerative  changes  peculiar  to  hered- 
itary syphilis,  are  grouped  among  the  parasyphilitic  affections.  It  is  also 
claimed  that  syphilis  furnishes  the  etiologic  soil  for  the  development  of  many 
constitutional  degenerative  changes,  leading  to  tuberculosis,  diabetes,  and  pos- 
sibly cancer. 

REINFECTION    IN    ACQUIRED    SYPHILIS. 

It  has  always  been  held  that  one  attack  of  syphilis  protects  against  a  sec- 
ond attack.  A  great  number  of  authentic  cases,  however,  have  been  recorded 
by  different  observers  which  would  seem  to  establish  beyond  question  the  pos- 
sibility of  reinfection.  Many  such  cases  have  been  reported  in  which  there 
was  an  interval  of  only  a  few  years — in  one  case,  two  and  a  half  years — ^between 
the  first  and  second  infection.  In  some  cases  the  surface  manifestations  of  a 
former  attack  were  plainly  evident  and  coincident  with  the  eruptive  phenomena 
of  the  second  infection. 

REINFECTION    IN    HEREDITARY    SYPHILIS. 

There  is  a  general  consensus  of  opinion  among  syphilographers  that  the 
subjects  of  hereditary  syphilis  gradually  acquire  a  susceptibility  to  the  con- 
tagion of  syphilis,  and  are  capable  of  contracting  the  disease  from  a  new  infec- 
tion. In  the  hereditary  form,  it  would  appear  that  the  immunity  against 
infection  gradually  loses  its  force,  and  in  many  cases  is  extinguished  at  the 
age  of  puberty  or  else  about  the  twenty-first  year.  There  are  many  authentic 
cases  on  record  of  heredo-syphilitics  who  have  acquired  syphilis  after  the 
twenty-first  year. 

MORBID    ANATOMY. 

In  the  necessarily  restricted  limits  of  this  article,  an  extended  account  of 
the  pathology  of  syphilis  cannot  be  entered  into.  It  may  be  said  in  a  general 
way  that,  histologically,  syphilis  belongs  to  the  class  of  infectious  granu- 
lomata.  All  the  lesions  of  syphilis,  irrespective  of  the  stage  of  its  evolution, 
possess  the  same  histological  characters.  These  consist  essentially  in  an  infil- 
tration of  round  or  embryonic  cells  in  the  connective  tissue  of  the  different 
organs,  producing  an  inflammatory  neoplasm  or  granuloma.  The  changes  in 
the  blood  vessels  may  be  intravascular,  constituting  endo-arteritis  or  endo- 
phlebitis ;  or  they  may  be  of  perivascular  origin.  Even  in  the  erythematous 
syphilide  there  is,  in  addition  to  the  hyperemia,  a  slight  cell  infiltration  per- 
meating and  surrounding  the  Avails  of  the  capillary  vessels  of  the  papillae  and 
corium.  The  spirocheta  pallida  is  found  in  the  walls  of  the  blood  ves- 
sels and  especially  abounds  in  the  perivascular  infiltration. 


398  SYPHILIS. 

In  the  SYpliilitic  papule,  which  represents  the  fundamental  type  of  all 
specific  lesions,  the  process  affects  principally  the  papillary  body.  By  exten- 
sion of  the  process  to  the  deeper  parts  of  the  derma  and  subcutaneous  tissues, 
the  tubercle  or  gumma  is  produced.  According  as  the  cellular  prolifera- 
tion affects  one  or  another  element  of  the  skin,  there  are  differences  in  the 
situation,  the  volume,  density,  and  conformation  of  the  lesions,  but  they  are 
all  united  by  the  lines  of  histological  identity. 

A  special  feature  of  syphilitic  infiltration  is  its  tendency  to  increase  by 
peripheral  extension,  so  that  the  borders  of  a  lesion  always  represent  the  most 
recent  cell  accumulation.  Another  distinctive  feature  is  that  the  inflammatory 
neoplasm  or  granuloma  is  incapable  of  organization  and  tends  to  disappear  by 
resorption  or  purulent  dissolution.  In  certain  lesions  of  the  gummatous  type 
there  is  a  tendency  to  sclerotic  or  fibrous  alterations,  with  caseous  or  other 
forms  of  gummatous  degeneration.  In  lesions  of  the  secondary  type  there  is 
a  resorption  of  the  infiltration  without  permanent  changes  in  the  vessels.  In 
lesions  of  the  tertiary  type  the  involutionary  changes  are  due  to  partial  or 
complete  obliteration  of  the  vessels  and  resulting  ischemia,  with  caseous  degen- 
eration, the  necrotic  changes  usually  beginning  in  the  centre  and  extending  to 
the  periphery. 

THE    SOURCES    AKD    MODES    OF    SYPHILITIC    CONTAGION. 

Sources  of  Contagion. — The  sources  of  syphilis  from  which  contagion  is 
commonly  acquired  are  the  secretions  of  the  chancre  and  of  certain  second- 
ary lesions,  more  particularly  mucous  patches.  The  blood  of  syphilitics  is 
inoculable,  and  consequently  contagious,  during  the  entire  secondary  stage. 
The  lymph  also  is  charged  with  the  virulent  principle  of  syphilis.  It  was 
formerly  thought  that  the  lymph  conveyed  the  syphilitic  contagion  only  when 
mixed  with  blood,  but  our  knowledge  of  vaccinal  syphilis  shows  that  the 
perfectly  clear  lymph-vaccine  vesicle  from  the  arm  of  a  syphilitic  subject, 
without  the  slightest  admixture  of  blood,  is  capable  of  conveying  the  disease. 
At  what  precise  moment  the  blood  becomes  impregnated  with  the  virulent 
principle,  and  at  what  moment  it  loses  this  virulent  property,  is  not  definitely 
known. 

It  was  formerly  supposed  that  none  of  the  physiological  secretions,  as  the 
milk,  saliva,  and  semen  of  syphilitics  is  contagious.  But  recent  developments 
in  our  knowledge  of  the  disease  has  modified  these  conclusions.  The  possible 
contamination  of  the  physiological  secretions  with  the  blood  of  glandular  cells 
should  not  be  overlooked.  The  tendency  is  towards  the  acceptance  of  the  view 
that  the  semen  may  be  contagious.  Finger's  experiments  have  shown  that 
monkeys  may  be  inoculated  with  syphilitic  semen,  with  positive  results.  It  is 
claimed  that  a  positive  result  has  been  obtained  by  Voss,  of  St.  Petersburg, 
who  inoculated  a  girl  with  milk  from  a  syphilitic  woman.  Levaditti,  who  has 
found  the  spirochete  in  the  renal  epithelium  of  syphilitic  infants,  suggests 
that   even   the    urine   mav   contain   contagious   elements.     The   saliva    of   the 


PEIMAEY    SYPHILIS.       THE    CHANCRE,  399 

syphilitic  may  be  the  accidental  vehicle  of  the  virus,  when  mixed  with  the  se- 
cretion of  mucous  patches  in  the  mouth. 

Modes  of  Contagion. — The  virulent  principle  of  syphilis  is  a  fixed  con- 
tagium,  and  may  be  conveyed  from  one  individual  to  another  by  either  direct 
or  mediate  contagion.  While  syphilis  is  commonly  acquired  through  the  direct 
inoculative  contact  of  the  genital  parts  in  sexual  intercourse,  it  may  originate 
entirely  independently  of  the  sexual  act.  Syphilis  may  be  acquired  in  the  act 
of  kissing  from  a  mucous  patch  in  the  mouth.  The  nipple  of  a  healthy  nurse 
may  be  infected  by  the  lips  of  a  syphilitic  infant,  and  a  healthy  infant  may  be 
infected  from  a  syphilitic  lesion  on  the  breast  of  a  nurse.  As  rarer  examples 
of  direct  contagion,  may  be  mentioned  digital  chancres  of  the  surgeon  or 
accoucheur  from  contact  with  syphilitic  lesions,  the  bite  of  a  syphilitic,  the 
operation  of  skin-grafting,  and  so  forth.  Any  object  upon  which  the  syphilitic 
virus  has  been  accidentally  deposited  may  serve  as  the  medium  of  contagion, 
such  as  spoons,  cups,  forks,  glasses,  pipes,  nursing  bottles,  children's  toys, 
speaking  tubes,  sponges,  surgical  instruments,  a  tongue  depressor  or  a  catheter, 
the  speculum,  dental  instruments,  the  razor,  and  objects  used  in  industrial 
occupations,  such  as  that  of  glass-blowers. 

A  healthy  woman  may  serve  as  the  conveyor  of  contagion  without  herself 
being  infected,  through  the  intermediary  of  syphilitic  discharges  deposited  in 
the  vagina  by  one  individual  from  which  the  next  comer  is  infected.  A  healthy 
wet  nurse  may  contaminate  a  healthy  infant  after  having  given  the  breast  to 
a  syphilitic  suckling.  In  vaccinating  a  number  of  persons,  one  of  whom  is 
syphilitic,  the  point  of  the  lancet  may  be  charged  with  his  blood,  and  the  next 
one  in  the  series  inoculated  with  syphilis. 


PRIMARY    SYPHILIS,    THE    CHANCRE    AND    BUBO. 

Chancre. — Whatever  may  be  the  mode  of  contagion,  the  first  effect  of  the 
virus  is  to  develop  at  its  point  of  entrance  into  the  system  a  lesion  of  syphilitic 
character,  designated  as  the  chancre  or  initial  lesion.  The  incubation 
period  of  the  chancre  is  three  or  four  weeks,  on  an  average  twenty-six  days, 
although  this  period  may  be  abbreviated  or  lengthened.  The  chancre  first 
appears  as  a  flat  papule  which  increases  in  size  and  hardness ;  the  surface 
gradually  becomes  eroded,  and  furnishes  a  slight  secretion  which  dries  into 
a  scab  or  crust.  Ulceration  of  the  chancre  is  caused  by  secondary  infection. 
In  most  cases  it  is  superficial;  but  it  may  become  deeper,  producing  a  cup- 
shaped  depression  or  excavated  ulcer.  In  a  few  days  the  base  of  the  chancre 
becomes  indurated,  and  this  induration,  which  constitutes  the  specific  mark  of 
the  primary  lesion,  varies  in  density  from  a  parchment-like  thickening  to  a 
cartilaginous  hardness.  When  grasped  by  the  fingers,  it  feels  like  a  hard, 
nodular  body  set  into  the  skin.  In  many  cases,  however,  the  induration  may 
be  so  slight  as  to  be  inappreciable.  This  is  especially  the  case  in  chancres  of 
the  vulva.     After  the  chancre  has  attained  a  certain  development,  it  remains 


400  SYPHILIS. 

stationary  for  two  or  three  weeks,  and  then  heals,  leaving  a  pigmented  spot 
which  gradually  disappears.  The  induration  often  remains  after  the  surface 
has  healed,  and  may  persist  for  several  weeks  or  months.  The  total  duration 
of  the  chancre,  when  uncomplicated,  rarely  exceeds  four  or  five  weeks. 

Chancres  vary  in  form,  dimensions,  extent,  and  depth  of  ulceration ;  the 
character  of  the  induration  present  and  the  objective  characters  may  also  be 
modified  by  the  intercurrent  processes  of  inflammation,  phagedena,  gangrene, 
and  so  forth.  The  most  common  varieties  are  the  superficial  erosion; 
the  ex-ulcerative  chancre;  and  the  excavated  ulcer,  or  Hunterian 
chancre,  the  clinical  difference  between  them  depending  upon  the  greater  or 
less  depth  of  the  ulcerative  action,  and  the  more  or  less  pronounced  character 
of  the  induration. 

The  her  pet  if  or  m  chancre  consists  of  a  cluster  of  vesicles  resembling 
herpes  progenitalis.  The  vesicles,  instead  of  drying  up  and  disappearing, 
coalesce,  and  the  base  of  the  ulcer  thus  formed  takes  on  the  characteristic 
induration. 

The  mixed  chancre  presents  the  objective  characters  of  both  chancroid 
and  chancre.  If  the  virus  of  the  chancre  and  chancroid  have  been  inoculated 
at  the  same  time,  the  lesion  first  presents  the  characters  of  the  chancroid  and 
later  the  base  of  the  ulcer  becomes  specifically  indurated.  In  the  mixed  chancre 
there  is  simply  an  association  without  combination  of  the  two  viruses.  It  is 
worthy  of  note  that  the  simultaneous  presence  of  the  bacillus  of  Ducrey 
and  the    spirocheta    pallida   has  been  demonstrated  in  mixed  chancre. 

It  was  formerly  thought  that  the  chancre  was  invariably  single,  but  more 
careful  observation  has  shown  that  it  is  often  multiple.  Diversity  in  the  form 
of  the  chancre  is  often  determined  by  the  anatomical  characters  of  the  tissues 
upon  which  it  happens  to  develop.  On  the  surface  of  the  glans  penis  it 
often  appears  as  a  dry  papule,  the  surface  of  which  is  scarcely  or  not  at  all 
eroded,  and  is  covered  with  whitish  scales.  Situated  in  the  balano-preputial 
furrow,  it  is  more  apt  to  be  elevated,  with  a  nodular  induration.  Chancre 
of  the  meatus  may  affect  one  or  both  lips  of  the  urethra  and  extend  into 
the  canal.  In  this  situation  it  is  apt  to  be  erosive,  and  may  take  on  a  phage- 
denic action.  Chancre  of  the  urethra  or  concealed  chancre,  while  com- 
paratively rare,  is  clinically  important,  since  it  is  frequently  overlooked,  and 
its  sero-sanious  discharge  may  be  mistaken  for  that  of  chronic  gonorrhea. 

Chancres  in  the  female,  from  their  situation  upon  parts  concealed 
from  observation,  and  their  indolent  and  painless  character,  often  pass  unper- 
ceived  by  the  patient.  They  most  frequently  occur  on  the  labia  majora, 
extremely  rarely  upon  the  vaginal  walls,  but  not  infrequently  upon  the 
cervix  uteri.  When  situated  upon  the  inner  surface  of  the  labia  or  upon 
surfaces  in  contact  and  kept  moist  by  the  natural  secretion,  they  are  frequently 
transformed  into  mucous  patches  or  condylomata. 

Multiple  chancres  are  almost  always  due  to  the  simultaneous  inocula- 
tion of  a  number  of  rents  and  abrasions,  but  they  may  be  produced  by  succes- 


VARIETIES    OF    CHANCRE.  401 

sive  inoculation.  Cases  are  reported  in  which  chancres  successively  developed 
as  late  as  from  the  fifteenth  to  the  twenty-fifth  day  after  the  first. 

Chancre  rednx,  or  relapsing  chancre,  may  appear  after  the  com- 
plete cicatrization  of  the  first  chancre,  presenting  all  the  characteristics  of  the 
primary  lesion. 

Extragenital  Chancres. — The  site  of  the  chancre  is  determined  alto- 
gether by  the  conditions  of  contact.  While  in  the  large  majority  of  cases  it 
is  situated  upon  the  genital  parts,  extragenital  chancres  are  comparatively  com- 
mon. They  have  been  found  on  almost  every  part  of  the  body,  except  the  soles 
of  the  feet;  likewise  every  portion  of  the  mucous  surfaces  accessible  by  contact 
may  be  the  seat  of  infection,  as  the  lips,  tongue,  tonsils,  or  the  conjunctival, 
nasal,  urethral,  or  anal  mucous  membranes.  The  three  regions  which  may  be 
regarded  as  centres  of  predilection  are  the  perigenital,  the  mouth,  and 
the  breast,  simply  because  these  parts  are  most  frequently  brought  into 
immediate  contact  with  the  infectious  virus. 

Labial  Chancre. — Chancre  of  the  lip  is  usually  single,  and  occurs  most 
frequently  on  the  lower  lip.  Owing  to  the  irritation  to  which  the  lip  is  sub- 
jected in  taking  food  and  other  causes,  chancre  in  this  situation  may  develop 
into  a  hypertrophic  form,  simulating  a  malignant  growth. 

Chancre  of  the  Tongue. — This  is  usually  situated  on  the  anterior 
third  of  the  dorsal  surface.  It  may  occupy  the  side  of  the  tongue,  which 
frequently  becomes  ulcerated  and  fissured  so  that  it  may  be  mistaken  for  a 
beginning  epithelioma. 

Chancre  of  the  Tonsil. — Chancre  of  the  tonsil  occurs  much  more  fre- 
quently than  was  formerly  supposed,  as  many  such  cases  were  not  identified. 
It  is  usually  attended  by  considerable  redness,  swelling  and  inflammatory  ex- 
udation. 

ISTasal  chancre  is  comparatively  rare.  The  contagion  may  be  effected  by 
means  of  the  fingers,  instruments,  penholders,  and  so  forth.  A  large  number 
of  cases  of  nasal  chancre  have  been  caused  by  catheterization  of  the  Eustachian 
tube  by  contaminated  catheters. 

Chancre  of  the  eyelid,  affecting  either  the  ciliary  border  or  the  con- 
junctiva, has  been  observed.  Contagion  may  be  effected  indirectly  by  the  fin- 
gers, or  by  contaminated  towels ;  or  directly  by  coughing  during  the  course  of  an 
examination  of  the  throat  of  a  person  affected  with  secondary  syphilis. 

Chancre  of  the  face  is  most  often  caused  by  kissing  or  by  the  use  of 
infected  shaving  utensils.  Occurring  on  the  bearded  portion  of  the  face,  it  is 
frequently  mistaken  for  ringworm,  or  even  for  epithelioma. 

Chancres  of  the  nipples  most  commonly  occur  from  contamination 
through  suckling  a  syphilitic  infant.  They  are  more  apt  to  be  multiple  in  this 
region  than  upon  any  other  part  of  the  body. 

Digital  chancres  have  a  special  interest  for  professional  men,  as  they 
themselves  are  the  most  frequent  sufferers  from  them.  They  are  most  com- 
monly acquired  by  digital  examination  or  manipulation  in  obstetrical,  gyn- 
27 


402  SYPHILIS. 

ecological,  or  surgical  work.  In  Fournier's  statistics  of  forty-nine  cases  of 
digital  chancre,  thirty  occurred  in  physicians.  Their  gi-eat  frequency  among 
professional  men  emphasizes  the  importance  of  using  great  circumspection  in 
making  vaginal  examinations  and  in  operations  upon  syphilitic  subjects.  They 
are  most  often  contracted  from  mucous  patches  of  the  vulva  or  from  mixed 
infections  or  concealed  lesions  in  persons  not  known  to  be  syphilitic.  ]\Iany 
physicians  called  to  a  woman  in  labor,  for  example,  are  accustomed  to  make  a 
digital  examination  without  inspection  of  the  genital  parts,  or  without  any 
knowledge  of  the  condition  of  the  patient's  health.  Cuts,  abrasions,  hang-nail, 
eczematous  eruptions,  or  any  break  of  the  epidermis  from  whatever  cause,  may 
be  a  point  of  entry  for  the  syphilitic  virus. 

Bubo. — Another  phase  of  the  primary  stage  of  syphilis  is  marked  by  the 
indolent  enlargement  of  the  nearest  lymph  glands  in  the  region  of  the  chancre 
and  sometimes  the  lymphatic  vessels  leading  thereto,  which  may  be  traced  in 
the  form  of  thickened  cords,  constituting  the  so-called  lymphangitis  of 
syphilis.  Induration  of  the  lymphatic  glands  is  the  most  constant  and,  from  a 
diagnostic  point,  the  most  valuable  sign  of  syphilitic  infection.  The  process 
usually  begins  in  the  first  or  early  in  the  second  week  after  the  appearance  of 
the  chancre.  The  glands  in  closest  anatomical  relation  to  the  chancre,  whatever 
its  situation,  are  always  the  first  involved.  Usually  one  gland  is  first  affected, 
and  later  a  number  of  contiguous  glands  undergo  the  same  process,  forming  a 
characteristic  chain.  The  bubo  of  syphilis  is  firm,  easily  movable  imderneath 
the  skin,  not  painful  on  pressure,  and  without  inflammatory  complication.  The 
three  specific  marks  of  mobility,  hardness,  and  indolence  serve  to  dif- 
ferentiate syphilitic  glands  from  any  other  morbid  process. 

Diagnosis  of  Chancre. — The  diagnosis  of  the  initial  lesion  of  syphilis  is  often 
a  matter  of  extreme  difficulty,  and  is  not  possible  within  the  first  few  days, 
before  it  has  become  the  seat  of  induration.  The  discovery  of  the  spirocheta 
pallida  in  the  secretions  or  smear  from  the  chancre  promises  to  facilitate  an 
early  diagnosis,  but  it  must  be  borne  in  mind  that  while  the  presence  of  this 
organism  is  decisive  of  syphilis,  the  failure  to  find  it  does  not  exclude  the 
disease.  The  result  of  an  examination  may  be  negative,  owing  to  imperfection 
in  the  technic  of  the  process. 

The  three  most  important  elements  upon  which  the  diagnosis  of  a  chancre 
is  based  are  the  period  of  its  incubation,  induration  of  its  base, 
and  specific  induration  of  the  neighboring  lymph  glands.  Each 
of  these  signs  may,  however,  have  a  deceptive  significance.  The  date  of  infec- 
tion cannot  always  be  determined,  the  induration  may  be  inflammatory,  and 
the  glands  may  be  sympathetically  swollen.  So  many  sources  of  error  are  pos- 
sible that  the  most  experienced  physician  cannot  always  pronounce  positively 
upon  the  syphilitic  character  of  a  venereal  sore  until  the  appearance  of  general 
symptoms. 

Herpes  progenitalis  may  be  confounded  with  chancre.  Simple  herpetic 
vesicles  occur  in  clusters,  they  are  more  superficial,  have  a  soft  base,  and  dis- 


DIAGNOSIS    AND    PEOGfNOSIS    OF    CHANCRE.  403 

appear  spontaneously  after  a  comparatively  short  duration;  moreover,  they  are 
multiple,  while  chancre  is  usually  single.  In  herpetiform  chancre,  the 
contour  of  the  lesion  is  more  circular,  the  base  becomes  indurated,  the  border 
thickened  and  prominent,  and  the  characteristic  glandular  complication  invari- 
ably follows. 

A  furuncular  lesion,  especially  when  upon  the  female  genitals,  has 
been  mistaken  for  chancre. 

In  the  great  majority  of  cases  where  a  patient  presents  herself  with  a  sore 
upon  the  genitals,  the  diagnosis  lies  between  chancre  and  chancroid.  The 
differential  features  are :  the  period  of  incubation ;  the  single  or  multiple  char- 
acter of  the  sores ;  the  depth  of  ulceration ;  and  the  peculiar  punched-out  ulcer, 
with  its  uneven,  w^orm-eaten  floor,  undermined  edges,  and  abundant  purulent 
secretion  of  the  chancroid,  in  contrast  with  the  smooth  surface  and  thin, 
sero-sanious  discharge  of  the  chancre.  The  induration  of  the  chancre  is 
sharply  defined,  while  that  of  the  chancroid  is  soft  and  shades  off  into  the 
surrounding  tissues.  The  bubo  of  chancre  is  almost  invariably  present,  with  en- 
larged glands  several  in  number,  hard,  indolent,  movable,  and  rarely  suppurating. 
The  bubo  of  chancroid  occurs  in  only  about  one-third  of  the  cases.  It  is  usually 
single,  inflamed,  painful,  and  often  suppurating.  Confrontation,  when  prac- 
tical, certainly  affords  a  valuable  indication,  but  its  trustworthiness  is  impeached 
in  all  cases  where  promiscuous  intercourse  has  been  indulged  in.  In  view  of 
the  frequent  occurrence  of  mixed  chancre,  however  strongly  clinical  probabili- 
ties point  in  favor  of  the  chancroidal  character  of  a  venereal  sore,  the  physician 
is  not  justified  in  positively  assuring  his  patient  that  it  may  not  be  followed  by 
constitutional  accidents. 

The  diagnosis  of  extragenital  chancre  is  rarely  made  in  its  devel- 
opmental stage,  partly  because  the  suspicion  of  the  physician  or  patient  of 
its  possible  venereal  nature  is  not  aroused.  The  chief  diagnostic  features  are, 
the  prolonged  persistence  of  the  lesion  during  several  weeks  without  undergoing 
marked  changes,  the  induration  at  its  base,  and  the  enlargement  of  the  nearest 
lymph  glands. 

Digital  chancres  are  especially  difficult  of  diagnosis,  as  they  often  pre- 
sent only  a  brownish  or  dusky-red  infiltration,  with  a  slightly  indurated  base 
with  no  characteristic  features. 

Prognosis  of  Chancre. — The  prognosis  of  the  chancre,  viewed  in  its  aspect  of 
a  local  lesion,  is  always  favorable.  It  is  essentially  self -limited,  with  a  tendency 
to  spontaneous  cure,  and  healing  generally  without  a  cicatrix.  When  compli- 
cated with  phagedena,  gangrene,  phimosis,  or  other  inflammatory  conditions, 
the  local  consequences  may  be  more  serious. 

The  prognostic  significance  of  extragenital  chancres  is  more  unfavor- 
able, as  they  are  subject  to  numerous  sources  of  irritation.  Chancres  of  the 
lip,  tongue,  and  pharynx  are  exposed  to  multitudinous  causes  of  irritation 
from  contact  with  food,  spices,  hot  liquid,  and  so  forth,  while  the  constant  move- 
ment of  the  parts  in  talking  and  swallowing  interferes  with  the  rest  necessary  to 


404  SYPHILIS. 

permit  of  healing.  Chancres  of  the  tonsil,  especially,  have  a  bad  prognosis, 
as  the  structure  of  the  tonsil  is  favorable  to  syphilitic  infiltration  and  its  crypts 
constitute  favorable  breeding  places  for  pyogenic  cocci.  Not  infrequently, 
chancres  of  the  tonsil  are  accompanied  with  malaise,  fever,  and  other  signs  of 
constitutional  disturbance,  due  doubtless  to  secondary  infection.  Chancres 
of  the  fingers,  especially  those  of  the  panaris  type,  are  proverbially  painful, 
and  apt  to  be  attended  with  severe  glandular  complications.  The  pain  is  readily 
explicable  from  the  character  of  the  tissues  involved,  the  structures  being  dense 
and  resisting  and  the  nail-bed  endowed  with  exquisite  sensibility.  The  digital 
chancre  is  subject  to  numberless  causes  of  irritation,  from  pressure,  painful 
contact,  and  so  forth,  besides  being  exposed  to  secondary  infection  from  pyogenic 
germs.  The  septic  process  thus  set  up  is  not  infrequently  attended  with  severe 
lymphangitis,  pyemia,  and  other  complications. 

Treatment. — Since  the  chancre  has  a  tendency  to  heal  spontaneously,  ex- 
pectant treatment  alone  is  necessary  in  the  majority  of  cases.  Rest,  clean- 
liness, and  an  aseptic  dressing  are  usually  the  only  measures  indicated. 
The  surface  may  be  dusted  with  calomel,  zinc  oxide,  or  xeroform. 
When  there  is  a  tendency  to  suppurative  action,  mild  astringents  and  the  use 
of  a  black  wash  may  be  employed.  In  inflammatory  conditions,  with  a  tendency 
to  gangrene,  solutions  of  permanganate  of  potash  and  a  mild  lotion  of 
chloride   of  zinc,   or  wet   boracic   acid   dressings,  are  indicated. 

Chancres  in  particular  situations,  as  in  the  meatus,  are  best  treated  with 
bougies  of  iodoform  or  tents  smeared  with  mercurial  ointment. 
Cases  of  concealed  chancre,  with  phimosis,  require  irrigations  through  a 
small  flat-nozzled  syringe,  inserted  under  the  prepuce.  We^k  solutions  of  bi- 
chloride of  mercury  or  silver  nitrate  may  be  employed.  The  volu- 
minous indurations,  which  sometimes  remain  after  cicatrization,  undergo  spon- 
taneous resorption,  but  their  involution  may  be  hastened  by  the  internal 
medication  of  mercury.  The  induration  of  the  lymphatic  ganglia  rarely  re- 
quires local  treatment.  When  they  become  painful  from  peri-glandular  in- 
flammation, the  use  of  mercurial  or  belladonna  ointment,  to  induce 
resolution,  is  of  service. 

Abortive  Treatment. — The  question  of  the  possibility  of  destroying 
the  syphilitic  virus  at  its  point  of  entrance,  and  thus  preventing  infection  of  the 
general  system,  has  been  settled  by  the  test  of  clinical  experience.  Abortive 
treatment  by  excision  or  destructive  cauterization  of  the  chancre  is  condemned 
by  its  clinical  results.  Brandes  excised  a  chancre  ten  hours  after  its  appear- 
ance, without  preventing  secondary  syphilis.  ISTiesser  stated  that  in  a  macaque, 
or  monkey,  in  which  the  inoculated  part  was  excised  eight  hours  after  inocula- 
tion, syphilis  developed  in  the  normal  way.  Experiments  by  Metchnikoff  and 
Roux  determined  that  the  period  of  localization  of  the  virus  does  not  exceed 
twenty-four  hours. 


THE    WASSEEMANN    REACTION.  405 

THE    WASSERMANN    REACTION:    THE    SERUM    DIAGNOSIS    OF 

SYPHILIS. 

Of  not  less  scientific  interest  and  certainly  of  as  much  practical  value  as  the 
discovery  of  the  microorganism,  the  causative  agent  of  syphilis,  has  been  the 
development  of  accurate  laboratory  serological  methods  for  determining  the 
existence  of  the  disease  in  suspected  individuals.  The  employment  of  serum 
diagnosis  has  taught  us  that  syphilis  is  even  more  protean  in  its  clinical  mani- 
festations than  had  hitherto  been  suspected.  It  has  shown  furthermore  that 
many  persons  supposedly  cured  still  suffer  with  the  disease.  It  has  offered 
a  means  of  early  diagnosis  and  of  accurate  determination  of  the  results  of  treat- 
ment. It  has  thrown  as  much  light  upon  the  diagnosis  of  syphilis  as  the  Widal 
reaction  has  upon  typhoid  fever,  and,  furthermore,  it  has  surpassed  the  latter 
method  in  indicating  the  results  of  treatment. 

The  medical  profession  owes  this  valuable  laboratory  test  to  Wassermann, 
E^eisser,  and  Brueck,  who  published  their  well-known  paper  in  the  Deutsch. 
med.  WocJienschr.,  May,  1906,  Vol.  32,  p.  745.  To  Hideyo  Noguchi,  of 
the  Eockefeller  Institute  for  Medical  Research,  must  be  accorded  great  credit 
for  simplifying  the  test  and  clearly  putting  before  the  practising  physicians  the 
methods  of  its  use,      ("  Serum  Diagnosis  of  Syphilis.") 

Technic. — The  test  consists,  first,  in  placing  in  a  test  tube  a  definite  quan- 
tity of  the  suspected  person's  blood  serum,  with  a  definite  quantity  of  an  alco- 
holic extract  of  a  syphilitic  organ,  notably  the  liver ;  second,  adding  to  this  a 
definite  quantity  qf  fresh  guinea-pig  blood  serum  and  allowing  this  mixture 
to  incubate  a  little  while  at  a  temperature  of  37°  C. ;  thirdly,  adding  a  definite 
quantity  of  immunized  and  inactivated  rabbit's  blood  serum,  and  lastly,  adding 
a  known  and  definite  quantity  of  sheep's  red  blood  corpuscles  in  a  salt  solution 
suspension  and  then  incubating  at  37°  C.  for  two  hours. 

If  the  suspected  serum  used  is  not  syphilitic,  there  will  be  a  complete  hem- 
olysis of  the  red  blood  corpuscles ;  that  is  to  say,  they  will  go  into  solution  and 
the  hemoglobin  will  be  diffused  throughout  the  mixture.  If,  however,  the  sus- 
pected serum  is  syphilitic,  no  such  reaction  occurs,  and  the  blood  corpuscles  re- 
main intact. 

The  phenomenon  is  dependent  on  the  fact  that  two  kinds  of  substances  must 
be  present  in  all  blood  serum  to  cause  it  to  hemolize  red  blood  corpuscles ;  these 
are  called  "  amboceptor  "  and  "  complement,"  two  groups  of  bodies  whose  chem- 
ical natures  are  unknown.  Complement  bodies  occur  in  all  fresh  blood  sera. 
They  readily  undergo  destruction  at  a  temperature  of  56°  C,  and  likewise  at 
room  temperature  in  two  or  three  days.  An  amboceptor  is  not  normally  pres- 
ent in  all  sera,  but  can  always  be  produced  by  injecting  an  animal  with  red 
blood  corpuscles  of  another  species.  Such  injections  produce  specific  ambocep- 
tors for  the  corpuscles  injected.  The  amboceptor  is  very  stable,  resists  the  tem- 
perature of  56°  C,  and  remains  in  a  serum  kept  on  ice  for  a  year.  If  a  serum 
containing  the  complement  alone  is  brought  in  contact  with  red  blood  corpus- 


406  SYPHILIS. 

cles  there  is  no  action  between  the  two  substances.  If  amboceptor  is  brought 
in  contact  with  its  specific  red  blood  corpuscle  antigen  there  is  an  immediate 
union  of  the  two.  Blood  corpuscles  so  united  are  spoken  of  as  sensitized  cor- 
puscles. If  thej  are  then  brought  in  contact  with  sera  containing  complement 
the  cells  are  immediately  hemolized.  Xeither  the  amboceptor  nor  the  comple- 
ment bodies  can  hemolize  unless  thej  act  together  and  in  unison. 

Of  the  five  factors  of  the  Wassermann  test,  three  constitute  what  is  called 
the  hemolytic  system.  These  are,  the  sheep  corpuscles,  the  inactivated  anti- 
sheep  rabbit  serum,  which  contains  no  complement  but  abundant  amboceptor, 
and  the  fresh  serum  of  the  guinea  pig,  which  contains  complement.  The  other 
two  factors  are  the  suspected  serum  and  the  extract  of  the  syphilitic  organ. 

"When  a  syphilitic  serum  is  brought  in  contact  with  a  syphilitic  extract  of 
the  liver,  as  in  Wassermann's  test,  there  results  a  chemical  combination,  and 
this  combination  possesses  the  property  of  fixing  the  complement  which  exists 
in  all  fresh  blood  sera.  It  is  upon  this  peculiar  property  of  the  syphilitic  anti- 
gen and  antibody  that  the  test  relies.  Neither  the  syphilitic  serum  alone  nor 
the  syphilitic  organ  extract  has  this  property.  "We  have  said  that  complement 
is  necessary  to  hemolysis.  If,  therefore,  we  combine  a  suspected  serum  with  a 
syphilitic  organ  extract,  and  then  add  complement  as  it  occurs  in  giiinea-pig 
blood,  all  of  the  complement  will  be  taken  up  by  the  combination.  Therefore, 
when  we  add  the  sheej:)  corpuscles  and  the  antisheep  rabbit  serum,  there  is  no 
hemolysis,  because  there  is  no  complement  present  to  cause  it.  On  the  other 
hand,  if  the  suspected  seriun  is  not  syphilitic,  there  is  nothing  present  which 
will  fix  the  complement  of  the  giiinea-pig  blood.  It  is,  therefore,  free  to  act 
with  the  amboceptor  in  the  antisheep  rabbit's  serum,  and  there  results  hemolysis 
of  the  blood  corpuscles  of  the  sheep  which  are  added. 

It  is  not  necessary  to  give  in  detail  the  technic  of  this  somewhat  complicated 
laboratory  procedure.  Many  different  kinds  of  combinations  have  been  sug- 
gested, none  perhaps  so  accurate,  however,  as  this  original  Wassermann  test. 

XogTichi  uses  normal  human  corpuscles  in  place  of  the  sheep's  corpuscle,  and 
furthermore,  makes  it  simpler  to  employ  the  various  essential  factors  of  the 
test.  Every  physician  is  advised  to  read  Xognchi's  excellent  analysis  of  his 
method. 

In  the  actual  carrying  out  of  the  test  one  must  always  employ  two  controls, 
one  with  a  serum  which  is  definitely  syphilitic  and  one  with  a  serum  which  is 
definitely  nonsyphilitic.  It  is  by  this  means  that  the  practitioner  sometimes 
gets  the  report  of  suspicious,  suggestive,  and  so  forth. 

It  cannot  be  too  much  emphasized  that  the  practical  carrying  out  of  the  work 
must  be  done  by  accurate  quantitative  methods,  difficult  for  the  general  prac- 
titioner. It  is  simple  for  the  physician  to  secure  the  blood  serum  just  as  for  the 
AYidal  reaction  and  send  it  to  the  nearest  man  prepared  to  make  the  test. 

TVhen  positive,  the  test  is  almost  specific  for  syphilis.  It  has  occasionally 
been  noted  in  carcinoma  and  in  scarlet  fever.  It  occurs  in  a  high  jjercentage 
of  leprosy  and  in  some  cases  of  yaws.     Xone  of  these  conditions  are  likely  to 


THE    WASSERMANN    KEACTION.  407 

be  confused  with  syphilis,  with  the  possible  exception  of  carcinoma,  and  here 
a  positive  reaction  is  rare. 

An  immense  literature  is  available,  giving  statistics  as  to  the  percentage  of 
positive  Wassermann  reactions  in  the  various  stages  of  syphilis.  L.  S.  Schmidt 
{Jour,  of  Med.  Assoc,  for  i^ov.  18,  1911,  Vol  57,  p.  1658)  gives  his  own 
statistics,  viz. : 

Percentage 

Primary  syphilis ; 93 

Secondary  syphilis 97 

Tertiary  syphilis 82 

Hereditary  syphilis 100 

Early  latent  syphilis  (treated  and  untreated) 56 

Late  latent  syphilis  (treated  and  untreated) 60 

Tabes 77 

General  paresis 98 

Cerebrospinal  syphilis 71 

The  reaction  appears  in  the  first  week  of  the  initial  lesion  in  about  twenty- 
five  per  cent  of  the  cases.  In  the  fourth  week  the  percentage  may  have  reached 
seventy  per  cent.  During  the  secondary  period  a  very  high  percentage  of  cases 
give  positive  reactions,  practically  all  congenital  cases  do  so.  In  cases  thor- 
oughly treated  with  mercury,  the  reaction  disappears  in  a  considerable  propor- 
tion of  the  cases  permanently ;  in  others  it  recurs  after  varying  intervals ;  in 
some,  particularly  the  congenital  types,  it  cannot  be  made  to  disappear, 

Salvarsan  has  less  power  in  determining  the  disappearance  of  the  reaction 
even  in  cases  where  it  gives  most  marked  betterment  of  the  clinical  manifesta- 
tions. However,  in  some  cases  a  single  dose  may  lead  to  the  permanent  disap- 
pearance of  the  reaction. 

The  employment  of  this  reaction  indicates  that  practically  all  prostitutes 
have  syphilis ;  it  shows  that  at  least  fifty  per  cent  of  the  mothers  of  hereditary 
syphilitic  children,  although  they  have  never  shown  any  signs  of  the  disease, 
have  it  in  a  latent  form. 

A  negative  Wassermann  reaction  is  not  of  so  much  value  as  a  positive,  and 
this  is  particularly  true  if  the  patient  has  been  under  treatment.  It  is  more 
true  of  cases  of  tertiary  and  primary  than  of  secondary  syphilis.  In  acute  sec- 
ondary syphilis  nearly  all  cases  are  positive. 

The  reaction  is  of  great  assistance  in  the  treatment  of  cases  because  our 
present  view  is  that  no  patient  who  presents  a  positive  Wassermann  reaction 
is  cured.  There  should  be,  therefore,  in  every  instance,  examinations  made 
at  stated  intervals  until  it  is  positively  known  that  the  reaction  is  permanently 
absent. 

To  sum  up,  the  Wassermann  test  should  be  made  in  every  case  of  suspected 
syphilis,  and  applied  during  the  treatment  as  a  means  of  determining  whether 
a  cure  has  resulted.  It  is  thus  possible  to  individualize  the  cases  in  their 
treatment. 


408  SYPHILIS. 


SALVARSAN. 


Salrarsan  is  an  arsenical  preparation,  the  proper  name  of  wliicli  is  dioxy- 
diamedo-arseno  benzol,  prepared  under  the  direction  of  Prof.  Paul  Ehrlich  by 
his  chemist,  Dr.  Berthheim,  and  first  put  in  the  hands  of  a  number  of  high- 
grade  clinicians  in  September,  1909.  The  newspapers  of  the  entire  civilized 
world  took  up  the  question  of  this  remedy,  and  long  accounts  of  it  occurred  in 
a  number  of  popular  magazines,  heralding  it  as  the  most  marvelous  drug  of 
the  ages,  and  attributing  to  it  the  power  of  completely  curing  syphilis  in  all  of 
its  stages  by  a  single  dose.  Unhappily,  this  enthusiastic  estimation  of  its  value 
has  not  been  proven  by  experience;  it  remains,  however,  a  most  valuable  rem- 
edy, relieving  certain  cases  of  syphilis  with  great  ease  which  resist  mercury 
and  potassium  iodide.     It  also  acts  efficiently  in  some  other  cases. 

The  energy  and  determination  shoT\Ti  by  Ehrlich  and  his  collaborators  in 
the  preparation  of  salvarsan  will  always  be  held  up  as  a  model  of  scientific 
work.  The  very  name  606  represents  the  number  of  this  preparation  in  a  long 
series  of  experiments  made  to  find  a  specific  for  the  disease. 

Salvarsan  is  dispensed  as  a  light  yellow  powder  in  a  closed  glass  capsule, 
from  which  the  air  has  been  excluded  and  replaced  by  wood  alcohol  vapor.  It 
is  an  acid  substance  and  readily  combining  with  an  alkali  and  dissolving  freely 
in  water.  Hata,  experimenting  with  rabbits,  showed  that  ten  milligrams  per 
kilo  was  sufficient  to  kill  all  the  spirochetes  in  a  single  dose,  and,  furthermore, 
that  this  was  only  one-seventh  of  the  lethal  dose.  In  man  a  dose  of  one  gTamme 
or  more  has  been  without  bad  effect.  In  the  early  months  of  its  use  the  aver- 
age dose  was  .3  grammes  =  5  gTains ;  the  average  dose  now  is  .5  grammes  =  3 
grains.  In  the  earliest  reports  it  was  thought  that  the  first  dose  must  be  large 
enough  to  destroy  all  the  organisms,  and  that  if  they  were  not  destroyed  by  the 
first  dose  they  became  immunized  against  the  salvarsan.  This  has  since  been 
proven  not  to  be  the  case. 

When  injected  into  the  body,  salvarsan  appears  in  the  urine  in  about  two 
hours,  and  may  continue  to  be  present,  according  to  ITeuser  (Med.  Klin.,  April 
9,  1911),  in  some  cases  for  from  three  to  nine  months.  When  injected  sub- 
cutaneously  or  intramuscularly,  a  large  quantitity  may  lodge  at  the  point  of 
injection.  When  injected  into  the  blood  direct,  as  Bornstein  (Deutsch.  med. 
^Vocllenscllr.,  Jan.  19,  1911)  showed  on  animals,  it  is  deposited  principally  in 
the  liver,  spleen  and  kidneys. 

Methods  of  Giving  Salvarsan. — Salvarsan  has  been  given  hypodermically,  in- 
tramuscularly, and  intravenously.  The  first  method  has  been  entirely  aban- 
doned owing  to  the  pain,  tendency  to  infection,  and  other  troubles.  The  sec- 
ond method  is  still  much  used,  but  has  marked  disadvantages,  in  that  a  large 
part  of  the  salvarsan  frequently  remains  unchanged  at  the  point  of  injection, 
leaving  painful  lumps  which  may  remain  for  months ;  in  every  case  also  there 
is  much  pain  associated  with  this  method.  The  best  way  is  to  inject  it  intra- 
venouslv.      A   number   of   different  technics   have   been   used    for    the    intra- 


SALVAKSAlSr.  409 

venous  injections,  all  of  them  uniting  in  the  common  characteristic  of  giving 
the  dose  greatly  diluted.  The  method  recommended  by  Keidel  and  Geraghty 
(Journ.  Amer.  Med.  Asso.,  Nov.  18,  1911,  Vol.  57,  p.  1660)  is  as  follows: 
Dissolve  the  salvarsan  in  100  c.c.  of  sterile  salt  solution;  make  alkaline  by 
adding  from  1.2  to  1.3  c.c.  of  four  times  normal  sodium  hydroxide  solution; 
then  add  normal  salt  solution  to  bring  the  total  value  up  to  240  c.c.  When 
made  in  this  way  each  40  c.c.  of  the  solution  contains  .1  grain  of  salvarsan. 
The  injection  is  made  by  means  of  a  glass  syringe  provided  with  a  two-way 
stopcock.  The  needle  of  this  syringe  is  forced  directly  into  one  of  the  super- 
ficial veins  of  the  forearm  near  the  elbow.  This  can  be  made  prominent  by 
placing  a  tourniquet  around  the  arm.  The  dose  should  be  about  .5  grammes  in 
the  average  case. 

After  this  dose  is  given  the  patient  should  be  put  to  bed  and  kept  there, 
we  think,  for  a  day  or  two ;  in  many  cases,  however,  the  salvarsan  is  given 
and  the  patient  allowed  to  immediately  go  home.  Often  there  is  a  rise  of 
temperature  for  a  day  or  two  after  the  dose.  This  is  particularly  noticeable  if 
there  are  numerous  and  active  lesions  at  the  time  the  remedy  is  given.  The 
remedy  is  contraindicated  in,  first,  serious  nonsyphilitic  diseases  of  the  retina 
and  optic  nerve ;  secondly,  severe  diseases  of  the  respiratory  and  circulatory 
system ;  thirdly,  in  all  cases  where  the  patient  is  very  low  or  in  bad  health 
due  to  other  diseases  than  syphilis.  It  is  indicated,  first,  in  all  cases  where 
mercury  cannot  be  tolerated ;  secondly,  in  all  cases  where  mercury  has  not 
cured ;  third,  in  all  primary  cases ;  fourth,  in  all  cases  which  show  a  persistent 
Wassermann  reaction  in  spite  of  treatment  with  mercury  and  potassium  iodide. 

As  a  general  principle  it  has  been  observed  that  the  results  are  truly  re- 
markable in  the  primary  cases  and  in  these  secondary  cases  with  lesions  on  the 
mucous  membrane.  Some  of  these  heal  as  if  by  magic.  The  results  have 
been  likewise  notable  in  some  of  the  cases  where  the  patients  are  in  very  bad 
general  health  owing  to  the  disease.  Appended  are  extracts  taken  from  the  arti- 
cle of  Keidel  and  Geraghty  referred  to.  These  extracts  are  a  fair  summary  of 
the  experiences  of  most  clinicians  who  have  employed  the  remedy.  It  is  a 
great  boon  in  the  treatment  of  syphilis,  but  does  not  replace  the  remedies 
already  in  use.  In  some  cases  it  acts  where  mercury  will  not  and  in  others 
is  inferior  to  the  mercury. 

Drs.  Keidel  and  Geraghty  say : 

"  Of  the  seventy  cases  treated  those  in  the  primary  stage  with  chancres  of 
from  one  to  three  weeks'  duration  gave  the  best  results.  Only  one  dose  was  given 
in  each  case  and  the  sore  healed  proinptly.  The  results  to  date  in  this  class  of 
cases  have  been  particularly  gratifying,  inasmuch  as  no  manifestations  of  the 
disease  have  appeared,  although  periods  of  from  two  to  five  months  have  elapsed 
since  the  treatment. 

"  Another  group  of  cases  in  which  the  results  seem  to  be  very  satisfactory 
is  that  in  which  the  patients  have  received  the  drug  following  a  vigorous  course 
of  mercury  for  periods  of  from  a  few  months  to  a  year  with  the  disease  under 


410  SYPHILIS. 

control  at  the  time.  Xone  of  the  cases  in  this  gronp  have  recnrred  clinically, 
and  in  all  that  we  have  been  able  to  follow  serologically,  the  Wassermann  reac- 
tion has  remained  negative.  Some  of  the  cases  have  now  been  under  observa- 
tion for  six  months. 

"  Cases  with  secondary  or  florid  syphilis,  however,  although  all  of  the 
lesions  and  clinical  manifestations  have  promptly  disappeared  following  the 
treatment  and  in  many  cases  the  Wassermann  has  become  negative,  almost  in- 
variably recur  at  a  later  date. 

"  In  cases  with  the  late  recurring  secondary  and  tertiary  lesions,  or  in 
which  more  or  less  diffuse  syphilitic  processes  are  present  in  the  body,  an  abso- 
lute eradication  of  the  disease  with  one  or  more  doses  of  the  drug  can  scarcely 
be  expected.  In  none  of  our  cases  of  this  type  have  we  been  able  to  accomplish 
permanent  residts  with  salvarsan  alone,  although  a  marked  beneficial  effect  on 
the  lesions  has  almost  always  been  observed. 

"  In  almost  every  case  in  which  visible  lesions  were  present  complete  dis- 
appearance followed  the  injection,  and  marked  improvement  in  the  general  con- 
dition of  the  patient  was  a  constant  feature.  In  all  cases  refractory  to  mercury, 
the  response  to  salvarsan  has  been  prompt  and  striking.  The  drug  is  indis- 
pensable for  the  treatment  of  patients  who  do  not  tolerate  mercury.  A  study 
of  our  statistics  does  not  warrant  us  in  expecting  a  complete  cure  of  syphilis 
and  absolute  immunity  from  recurrences  in  the  majority  of  cases  after  the  use 
of  only  one  or  two  injections.  A  small  number  of  cases  which  have  been  fol- 
lowed by  us  for  four  or  five  months  without  recurrences  justifies  the  belief 
that  one  injection  of  salvarsan  will  effect  a  complete  cure  in  some  cases.  Sal- 
varsan is  without  doubt  of  equal  value  with  a  long  course  of  mercury  and  potas- 
sium iodide  in  the  cure  of  lesions.  It  has,  however,  the  very  great  advantage  of 
simplicity  of  administration  and  causes  the  lesions  to  disappear  with  great  rapid- 
ity. Moreover,  it  saves  the  patient  from  the  damage  done  by  the  luetic  toxin 
during  the  period  necessary  for  the  control  of  the  disease  by  means  of  mercury. 

"  We  want  particularly  to  emphasize  the  fact  that  the  use  of  salvarsan  has 
passed  beyond  the  experimental  stage.  One  should  no  longer  make  it  his  object 
to  see  how  much  good  can  be  done  with  one  or  more  injections  of  this  drug,  but 
rather  of  how  much  value  it  can  be  made  to  assume  in  the  treatment  of  syphilis 
when  combined  with  other  drugs. 

"  The  superior  ability  of  salvarsan  over  mercury  to  rajDidly  kill  the  Spiro- 
chetie  pallid^e  in  the  tissues  has  been  demonstrated  beyond  question,  and  salvar- 
san has  therefore  been  indicated  in  every  case  of  syphilis,  when  not  specially 
contraindicated,  even  in  those  cases  in  which  it  seems  advisable  to  supplement  it 
with  the  subsequent  use  of  mercury. 

'"  From  our  experience  at  present,  we  strongly  advocate  a  vigorous  course 
of  mercury  following  the  injection  of  salvarsan  continued  for  about  six  months, 
and  then  possibly  followed  by  another  dose  of  salvarsan.  In  the  primary  cases 
and  those  already  well  under  control  with  mercury,  it  seems  fairly  probable 
that  salvarsan  may  be  sufiicient  to  eradicate  the  disease," 


CHAEACTEEISTICS    AND    VARIETIES    OF    THE    SYPHILIDES.  411 

SECONDARY    SYPHILIS.      THE    SYPHILIDES. 

The  eruptions  upon  the  skin  and  mucous  membranes  produced  by  syphilis 
are  termed  syphilides.  While  the  macule,  the  papule,  the  pustule,  and  the 
tubercle  represent  the  four  fundamental  types  of  syphilitic  lesion,  the  combina- 
tion or  blending  together  of  elementary  forms  has  led  to  the  necessity  of  using 
compound  names,  such  as  erythemo-papular,  papulo-pustular,  papulo- 
squamous, pustulo-crustaceous,  tuberculo-nlcerous,  in  order  to 
define  their  anatomical  characters  with  greater  accuracy.  Some  writers  recog- 
nize the  vesicular  or  bullous  syphilide,  but  the  vesicular  element  is  usually 
accidental,  due  to  the  intensity  of  the  inflammatory  process,  and  of  limited 
duration.  The  bullous  syphilide  cannot  be  considered  a  distinct  type, 
since  lesions  which  begin  as  bullae  rapidly  undergo  a  purulent  transformation; 
it  is  an  exceedingly  rare  manifestation  of  acquired  syphilis,  found  almost  ex- 
clusively in  the  hereditary  form. 

General  Characteristics.- — Although  syphilitic  skin  diseases  consist  of  the  same 
eruptive  elements  as  are  met  with  in  other  forms  of  cutaneous  disease,  yet  they 
are  impressed  with  certain  peculiarities  which  reveal  more  or  less  distinctly 
their  specific  origin,  and  often  enable  the  skilled  physician  to  recognize  their 
nature  at  a  glance.  These  peculiarities  are  associated  with  their  mode  of  evolu- 
tion, their  polymorphism,  color,  configuration,  gTOuping,  the  character  of  the 
scales,  crusts,  cicatrices,  the  absence  of  pain  or  other  subjective  symptoms.  The 
distinctive  features  are  especially  manifest  in  their  raw-ham  or  coppery  color ; 
their  symmetrical  distribution  in  secondary  syphilis ;  and  their  tendency  to 
form  circles  or  segments,  giving  rise  to  the  characteristic  crescentic,  serpiginous, 
and  horseshoe  shapes  of  the  ulcerative  lesions. 

Varieties. — The  early  eruptions  of  syphilis,  like  the  exanthemata  of  other 
blood  poisons,  may  be  distributed  over  the  whole  surface  of  the  body,  yet  each 
eruptive  form  manifests  a  predilection  for  certain  regions:  the  erythematous 
syphilide  for  the  chest,  trunk,  and  flexor  surf  aces ;  the  papular  syphilide 
for  the  face,  brow,  margin  of  hairy  scalp,  back  of  neck,  head,  and  limbs ;  the 
squamous  syphilide  for  the  palmar  and  plantar  surfaces;  the  pustular 
syphilide  for  the  parts  covered  with  hair;  the  ecthymatous  eruptions 
most  commonly  affect  the  limbs,  and  principally  the  lower;  tubercular 
lesions  are  found  everywhere;  moist  papules  have  a  predilection  for  the 
natural  orifices,  as  the  commissure  of  the  lips,  the  entrance  to  the  nares,  the 
genital  and  anal  folds,  or  any  place  in  which  the  skin  is  thin  and  delicate  and 
exposed  to  moisture  and  friction. 

The  apruriginous  character  of  the  syphilitic  eruption  constitutes  a  valuable 
differential  sign.  The  patient  may  be  unconscious  of  its  existence,  so  far  as 
subjective  sensations  are  concerned. 

The  Erythematous  Syphilide,  variously  designated  as  the  macular 
syphilide,  roseola  syphilitica,  etc.,  is  the  earliest  as  well  as  one  of  the 
commonest  cutaneous  manifestations  of  syphilis,  appearing,  usually,  from  seveii 


412  SYPHILIS. 

to  eight  "weeks  after  the  chancre.  It  probably  occurs  in  nearly  all  cases,  but 
from  the  absence  of  subjective  sensations  and  the  peculiarity  of  its  localization 
upon  parts  habitually  covered  by  the  clothing,  it  may  entirely  escape  observa- 
tion. The  eruption  first  appears  on  the  sides  of  the  chest  and  abdomen,  less 
commonly  on  the  limbs,  and  rarely  on  the  face.  It  consists  of  rounded  or  oval 
spots,  the  color  being  at  first  bright  red  or  pink,  and  disappearing  upon  pres- 
sure; later  it  deepens  into  a  yellowish-brown  pigmentation,  unaffected  by 
pressure.  The  spots  vary  in  number  and  degree  of  coloration;  sometimes  they 
are  few  and  scattered,  at  other  times  thickly  disseminated,  like  the  macules  of 
measles.  They  may  be  so  pale  as  to  be  hardly  perceptible,  giving  the  skin  a 
faintly  marbled  aspect ;  at  other  times  they  are  vividly  prominent. 

The  Maculo-papular  Syphilide  is  an  exaggerated  or  advanced  devel- 
opment of  the  macular  variety.  The  eruptive  spots  are  slightly  elevated,  situ- 
ated upon  an  erythematous  base,  and  sometimes  covered  with  fine  desquamating 
scales.  Occasionally,  one  or  more  larger  papules  make  their  appearance  in  the 
centre  of  the  erythematous  patch.  After  its  complete  involution,  syphilitic 
roseola  may  recur  a  number  of  times  during  the  first  or  even  the  second  year 
of  the  disease.  With  each  recurrence  the  spots  are  fewer  in  number,  as  well  as 
larger,  and  paler  in  appearance. 

Diagnosis. — S  y  p  h  i  1  i  t  i  c  roseola  may  be  differentiated  from  simple  roseola 
by  the  absence  of  febrile  symptoms  and  itching,  and  by  the  coincidence  of  other 
signs  of  syphilis,  such  as  the  history  of  a  chancre  and  the  presence  of  enlarged 
glands. 

The  Macular  Syphilide  often  resembles  closely  the  eruption  of 
measles.  The  characteristic  development  of  the  latter  upon  the  forehead  and 
back  of  the  ears,  the  suffusion  of  the  eyes,  and  the  catarrhal  symptoms  are  suf- 
ficient to  make  the  diagnosis.  A  copaibal  rash  is  sometimes  mistaken  for 
syphilitic  roseola,  but  in  the  former  the  spots  are  redder,  more  rounded  and 
discrete,  and  situated  especially  about  the  joints  and  on  the  backs  of  the  hands. 
They  are  also  characterized  by  an  intense  burning  and  itching.  In  its  declining 
stage  syphilitic  roseola  may  be  mistaken  for  pityriasis  versicolor.  The 
latter  affection  is  easily  differentiated  by  its  yellowish-brown  color,  and  the  fact 
that  the  pigmentation  may  be  removed  by  scraping  or  washing,  while  the 
syphilitic  spots  are  unaffected  by  these  means.  Pityriasis  rosea  has  also 
been  mistaken  for  syphilitic  roseola.  The  spots  of  the  former  are  the  seat  of 
active  desquamation,  while  the  latter  never  desquamate.  Erythema  multi- 
forme may  be  distinguished  from  syphilitic  roseola  as  the  eruption  is  more 
discrete,  purplish  in  color,  and  chiefly  affects  the  wrists,  ankles,  and  limbs. 

The  Pigmentary  Syphilide. — This  comparatively  rare  manifestation 
of  syphilis,  which  is  also  known  as  leu  coder  ma  syphiliticum,  may  occur 
in  the  early  secondary  stage  or  as  late  as  the  third  year.  It  is  much  more  com- 
mon in  women  than  in  men.  Its  favorite,  though  not  exclusive  seat,  is  the  sides 
of  the  neck,  sometimes  the  back  of  the  neck  and  shoulders.  It  very  rarely 
occurs  on  the  face  or  extremities.     It  consists  of  irreo'ularlv  rounded  circles  or 


DIAGKOSIS    OF    THE    SYPHILIDES.  413 

islets,  of  a  brownish  color,  isolated  or  confluent,  not  elevated  above  tlic  surface, 
and  not  scaly.  The  true  character  of  the  pigmentary  syphilide,  and  its  relation 
to  the  syphilitic  process,  has  not  been  definitely  determined.  It  is  probably 
due  to  some  localized  abnormality  in  the  distribution  of  pigment  matter,  pro- 
ducing a  loss  of  pigment  in  spots  and  a  hyperchromia  of  the  intermacular  and 
surrounding  spaces.  The  duration  of  this  syphilide  is  usually  prolonged.  It  is 
apparently  uninfluenced  by  treatment. 

While  the  nature  and  mode  of  production  of  the  pigmentary  syphilide  is 
somewhat  obscure,  its  presence  is  regarded  as  pathognomonic  of  syphilis.  It  must 
be  disting-uished  from  uterine  chloasma,  which  rarely  affects  the  neck; 
from  Addison's  disease,  in  which  the  pigmentation  is  more  diffused ;  from 
vitiligo,  in  which  the  leucoderma  is  more  pronounced,  and  in  which  there 
is  an  absence  of  hyperchromia  which  characterizes  the  pigmentary  syphilide. 

The  Papular  Syphilide. — The  papular  syphilide  in  the  extent  of  its 
distribution,  the  variety  of  its  lesions,  its  prolonged  continuance,  and  its 
pathological  significance,  is  the  most  important  of  the  group  of  secondary  erup- 
tions. It  usually  makes  its  appearance  from  the  third  to  the  fourth  month.  It 
may  immediately  succeed,  or  develop  coincidently  with,  the  erythematous 
form,  but  its  appearance  may  be  postponed  by  early  specific  treatment.  Recur- 
ring crops  of  the  eruption  may  appear  during  the  entire  secondary  stage,  and 
even  in  the  early  tertiary  stage;  it  often  merges  by  insensible  gradations 
into  the  tubercular  form.  The  eruption  consists  of  distinctly  circumscribed, 
solid  elevations,  from  the  size  of  a  pin-head  to  that  of  a  lentil,  and  sometimes 
considerably  larger,  resting  upon  an  erythematous  base.  In  form  they  may 
be  either  prominent  or  flat.  When  the  papule  attains  its  full  development,  it 
is  covered  by  a  dry,  shining  skin,  exceedingly  tense  over  the  surface  from  the 
cellular  infiltration ;  this,  upon  desquamating,  forms  a  sort  of  collar  of  broken, 
partly  detached  epidermis  around  the  periphery.  The  papules  undergo  in- 
volution, and  the  color,  which  at  first  is  bright  red,  changes  to  a  purplish-red, 
and  then  gradually  fades  out.  According  to  their  form,  volume,  and  other 
objective  characters,  papular  lesions  have  been  classified  as  follows:  the  lentic- 
ular papule,  the  miliary  papule,  the  squamous  papule,  and  the 
moist  papule.  This  division  does  not  imply  four  distinct  varieties,  but  in- 
dicates the  varying  form  which  the  papular  eruption  assumes,  according  to  its 
location  and  the  mode  of  its  evolution. 

The  Lenticular  Syphilide. — This  eruptive  form  is  the  most  common 
and  characteristic  of  the  secondary  manifestations  of  syphilis.  The  papules 
are  rounded,  oval,  and  slightly  elevated,  the  lesion  gaining  in  superficial  extent 
what  it  loses  in  height.  The  surface  is  at  first  smooth  and  flattened;  later  it 
presents  a  depression  in  its  centre,  the  desquamating  epidermis  forming  a  fringe. 
In  certain  localities  the  papule  may  attain  the  dimensions  of  a  twenty-five  or 
fifty-cent  piece,  and  is  then  known  as  the  nummular  syphilide.  The  larger 
lesions  present  a  firm,  well-defined  border,  with  a  smooth,  plain  surface.  Some- 
times the  margins  are  elevated  with  a  shallow  depression  in  the  centre,  which 


414  SYPHILIS. 

gives  them  an  umbilicatecl  appearance.  The  development  of  these  papules  upon 
the  brow  and  margins  of  the  hairy  scalp  constitute  a  peculiar  feature,  known 
as  the   "^'corona   veneris." 

The  Miliary  Papular  Syphilide  or  Lichenoid  Syphilide. — 
The  small  or  miliary  syphilide  is  perhaps  the  most  infrequent  variety  of  the 
papular  form  of  eruption,  representing  a  proportion  of  less  than  ten  per  cent. 
It  consists  essentially  of  an  infiltration  of  the  follicular  structures.  The  in- 
filtration is  confined  to  the  apex,  and  does  not  involve  the  base  of  the  papule. 
The  form  is  that  of  minute,  conical  or  pointed  projections,  the  size  of  a 
pin-head  or  millet-seed,  gTouped  in  circles  or  segments  of  circles,  each  group 
consisting  of  from  ten  to  forty  lesions.  These  efflorescent  patches  are  dis- 
tributed over  large  surfaces,  principally  invading  the  trunk  and  limbs,  back  of 
shoulders,  and  sternal  region.  In  another  variety  of  the  miliary  syphilide,  the 
papules  are  larger,  more  rounded,  less  numerous,  and  not  so  characteristically 
gTouped.  This  syphilide  is  characterized  by  being  exceedingly  persistent  and 
rebellious  to  treatment. 

As  the  name  implies,  the  small  papular  syphilide  or  lichen  syphiliticus 
presents  certain  resemblances  to  lichen  planus.  In  lichen  planus  the 
papules  are  smooth,  shiny,  flat,  and  often  have  a  central  depression,  giving 
them  a  slightly  umbilicated  appearance ;  they  have  a  tendency  to  group  in 
placards.  It  is,  moreover,  quite  pruriginous.  When  the  miliary  papules  are 
closely  aggregated  and  desquamate  abundantly,  they  bear  a  resemblance  to  a 
diffused  patch  of  psoriasis.  Minute  examination  shows  that  the  syphilitic 
papules  are  not  confluent,  but  simply  coherent  at  their  bases,  while  the  psoriatic 
papules  are  coalescent  and  the  surface  of  the  psoriatic  patch  is  more  or  less 
uniformly  covered  with  large  scales. 

The  Papulo-squamous  Syphilide. — An  important  modification  of 
the  papular  type  of  syphilis  is  characterized  by  a  marked  proliferation  of  the 
epidermal  elements,  which  collect  on  the  surface  in  the  form  of  dry  scales,  more 
or  less  adherent,  simulating  the  appearance  of  psoriasis.  The  mildest  mani- 
festations of  this  squamous  process  are  in  the  form  of  minute  furfuraceous  or 
branny  scales,  termed  syphilitic  pityriasis.  A  more  pronounced  develop- 
ment of  the  scale  is  often  seen  in  the  larger  and  more  prominent  lesions  of  the 
late  secondary  stage.  A  single  papule  may  enlarge,  or  several  papules  may 
coalesce,  forming  diffuse  patches,  usually  crescentic  or  circinate  in  form,  cov- 
ered with  dry,  adherent  scales,  and  giving  a  most  deceptive  resemblance  to 
patches  of  psoriasis. 

In  making  a  diagnosis  between  the  two  it  must  be  remembered  that  the 
scales  of  a  syphilitic  lesion  are  thicker  than  those  of  psoriasis ;  they  are  usually 
of  a  dirty-white  color,  and  lack  the  glistening,  silvery-white  appearance  and 
stratified  formation  of  psoriatic  scales.  When  the  scales  are  detached  from  a 
syphilitic  papule,  the  subjacent  infiltration  appears  deeper,  elevated  at  the  bor- 
der, and  with  a  reddish-brown  centre.  When  the  psoriatic  patch  is  denuded  of 
scales,  there  is  presented  a  hyperemic  surface,  with  a  number  of  bleeding  points. 


DIAGNOSIS    OF    THE    SYPHIT.IDES.  4^5 

Circinate  Papular  Sypliilide  in  certain  locations,  wlien  covered  with 
yellowish,  greasy  epithelial  scales,  may  present  a  strong  resemhlance  to  the 
annular  patches  of  seborrhea.  They  are  differentiated  rather  by  their  his- 
tory or  the  presence  of  other  symptoms  of  syphilis  than  by  differences  in  the 
objective  characters  of  the  lesions. 

The  Palmar  and  Plantar  Syphilides. — Syphilitic  papules  upon  the 
palms  and  soles  present  certain  modifications  in  form  and  aspect,  due  to  the 
thickness  of  the  epidermis  of  these  regions.  They  derive  a  special  clinical 
interest  and  importance  from  the  fact  that  they  bear  such  a  close  resemblance 
to  the  lesions  of  psoriasis  and  eczema  of  the  palms  and  soles  that  it  is 
difficult  to  differentiate  them.  They  may  develop  in  the  first,  second,  or  third 
year  of  syphilis,  or  their  chronological  limit  may  be  extended  to  five  or  ten 
years,  or  even  longer.  In  the  earlier  period  they  are  usually  bilateral,  later 
they  are  more  often  unilateral.  The  later  lesions  often  appear  in  the  form  of 
flat,  livid  spots,  the  surface  of  which  desquamates  and  comes  off  in  scales.  The 
papules  may  coalesce  and  form  infiltrated  patches,  usually  crescentic  or  cir- 
cinate in  form,  with  a  tendency  to  heal  in  the  centre  while  advancing  at  the 
periphery.  In  the  natural  furrows  of  the  palms  and  fingers  deep  creases  or 
fissures  are  apt  to  occur,  occasioning  much  pain  and  inconvenience,  which  is 
aggravated  by  their  exposure  to  pressure,  friction,  and  other  causes  of  irri- 
tation. 

The  designation  of  these  syphilides  as  palmar  and  plantar  psoriasis 
would  indicate  a  marked  resemblance  or  identity  of  the  objective  characters  of 
the  lesions.  Psoriasis  is  rarely,  if  ever,  limited  to  these  regions,  but  when 
found  there  is  always  associated  with  the  development  of  the  disease  upon 
other  parts  of  the  body.  A  psoriasiform  eruption,  limited  to  the  palms,  is 
almost  pathognomonic  of  syphilis.  The  differentiation  from  eczema  is  exceed- 
ingly difficult  and  often  impossible.  Syphilis  generally  begins  in  the  middle 
of  the  palm  and  spreads  centrifugally.  The  coppery  wall  of  infiltration  which 
marks  its  advancing  border  is  irregular  and  scalloped  in  outline ;  its  outer  edge 
is  sharply  defined  and  terminates  abruptly.  Eczema,  on  the  contrary,  usually 
begins  on  the  wrist  or  the  root  of  the  palm  or  fingers,  or  upon  the  dorsum  of 
the  hand,  where  syphilis  is  rarely  found.  Eczematous  infiltration  is  more  uni- 
form and  evenly  distributed  and  the  infiltration  does  not  terminate  so  abruptly. 
Eczema  is  further  distinguished  by  severe  itching,  which  is  absent  in  syphilis. 

The  Moist  Papular  Syphilide. — This  type  of  eruption  is  found 
where  the  skin  is  delicate  and  moist,  or  in  the  natural  creases,  where  contigu- 
ous surfaces  come  in  contact.  The  epidermis  becomes  macerated  and  eroded, 
and  there  is  a  transformation  of  the  dry  into  the  moist  papule.  Moist,  cutane- 
ous papules  may  occur  upon  the  genital  or  anal  regions,  on  the  breast  of  the 
female,  the  nates,  and  groin,  between  the  toes,  or  wherever  the  skin  is  fine  and 
humid.  They  are  laden  with  the  poison  of  syphilis  and  are  ultra  contagious. 
The  spirocheta  pallida  is  found,  often  abundantly,  in  the  scrapings  from 
these  lesions.    The  condyloma  latum  is  especially  common  in  the  vulvar  region, 


416 


SYPHILIS. 


and  also  occurs  in  men  on  the  scrotum  and  perineum.  Tlie  papules  often  fuse 
together  and  form  large  placards  which  may  extend  to  the  perigenital  parts, 
often  forming  large  cauliflower  gTOwths,  with  fissures  and  ulcerations.  The 
spirocheta  j^^Hi^a  is  found  abundantly  in  these  condylomatous  patches. 
On  the  mucous  surface  of  the  vulva  the  moist  syphilide  is  seen  in  the  form  of 
erosions  and  mucous  patches.  They  possess  a  special  importance  from  the  fact 
that  they  are  the  most  frequent  sources  of  the  syphilitic  contagion. 

Condylomata  lata   are  apt  to  be  confounded  with  the  vegetations  of  gon-, 
orrheal,  chancroidal,  and  other  irritating  conditions  of  a  non-syphilitic  nature. 
The   acuminate  vegetations   from  chancroid  or  gonorrhea  are  more  apt  to 
be  distinctly  pedunculate,  with  a  branched  dendritic  character  of  gTowth,  and  a 
more  distinctly  warty  surface. 

The  Pustular  Syj)hilide. — This  type  is  more  properly  termed  papu- 
lo-jDustular,  as  it  represents  an  advanced  stage  of  the  papule.  In  some  cases 
pustulation  occurs  so  rapidly  that  the  primary  papular  form  is  not  distinguish- 
able. Exceptionally,  the  eruption  may  begin  as  distinct  pustules.  The  so- 
called  vesicular  syphilide  may  also  be  grouped  under  this  division  as 
the  vesicular  element  is  rapidly  transformed  into  pus.  While  the  macular  and 
papular  eruptions  usually  precede  the  pustular  syphilide,  the  latter  may  excep- 
tionally occur  as  the  initial  eruption.  The  early  presence  of  the  pustular  erup- 
tion indicates  a  bad  type  of  syphilis,  since  it  is  an  expression  of  a  depraved 
state  of  the  patient's  constitution.  The  more  superficial  forms  are  ranged 
among  the  secondary  manifestations.  The  deeper  and  more  destructive  forms 
of  a  pustulo-ulcerous  character  may  develop  coincidently  with  distinctively  ter- 
tiary lesions.  Malignant  syphilis  is  usually  manifested  in  precociously  devel- 
oped pustular  lesions. 

The  following  varieties  of  the  pustular  syphilide  may  be  distinguished :  the 
acne-form,    variola-form,    impetigo-form,    and    ecthyma-form. 

In  the  acne-form  syphilide  the  follicular  structures,  sebaceous  glands  and 
hair  follicles  are  chiefly  aflected.  Suppuration  takes  place  wathin  the  follicles. 
The  lesions  are  of  various  sizes,  from  that  of  a  pin-head  to  larger,  situated 
upon  a  reddened  infiltrated  base.  Upon  the  scalp  this  syphilide  frequently 
constitutes  one  of  the  earliest  of  the  secondary  manifestations,  but  from  its 
location  it  is  frequently  overlooked.  It  may  occur  upon  the  forehead,  back  of 
neck,  shoulders,  buttocks,  and  outer  aspects  of  the  limbs. 

The  acne-form  syphilide  bears  a  close  resemblance  to  acne  vulgaris. 
It  may  be  distingaiished  by  the  smaller,  more  uniform  size  of  the  papules,  their 
dark,  coppery  color,  and  the  absence  of  comedones ;  the  coexistence  of  other  signs 
of  syphilis  is  also  a  differentiating  feature. 

The  variola-form  syphilide  occurs  in  the  form  of  dull-red,  infiltrated 
spots,  the  epidermis  over  which  becomes  distended,  with  a  serous  or  sero-puru- 
lent  fluid.  In  a  few  days  they  become  flattened  and  depressed  in  the  centre, 
with  the  formation  of  an  adherent  crust,  formed  by  the  drying  of  the  purulent 
elements.    It  especially  affects  the  face,  trunk,  and  limbs. 


DIAGNOSIS    OF    THE    SYPHILIDES.  417 

This  syphiloderm  has  an  additional  clinical  importance  from  its  resemblance 
to  varicella  or  variola.  The  resemblance  is  heightened  by  the  frequent 
occurrence  of  more  or  less  febrile  disturbance.  From  varicella  it  may  be 
distinguislied  by  the  absence  of  itching  and  other  signs  of  inflammatory  disturb- 
ance of  the  skin,  and  by  its  more  chronic  and  sluggish  develox3ment.  The 
changes  in  varicella  are  more  rapid.  In  addition,  varicella  is  essentially 
a  disease  of  childhood,  while  syphilis  is  more  common  in  adult  life. 

From  variola  the  distinction  is  not  so  readily  made.  Hutchinson  says: 
"  The  simulation  of  the  variolous  eruption  by  syphilis  is  the  most  marked  ex- 
ample of  '  syphilitic  imitation.'  "  The  differential  points  are :  the  history  of 
the  case,  the  more  chronic  evolution  and  course  of  the  syphilitic  eruption,  the 
brownish,  coppery  color  of  the  lesions,  and  the  absence  of  the  intense  prodromal 
symptoms  which  usher  in  an  attack  of  small-pox. 

The  impetigo-form  syphilide  is  a  flat,  superficial  pustule,  the  exuda- 
tion from  which  quickly  dries  into  a  greenish-brown  adherent  crust  which,  upon 
its  removal,  leaves  an  uneven  surface.  Not  infrequently  the  crustaceous 
pustules  run  together  and  form  patches,  constituting  tlie  confluent  im- 
petiginous syphilide.  In  the  variety  known  as  impetigo  rodens,  the 
ulcerative  process,  instead  of  being  limited  to  the  superficial  layers,  involves 
the  entire  thickness  of  the  skin.  This  form  presents  a  great  similarity  to  the 
ulcero-crustaceous  lesions  of  the  tertiary  stage  of  syphilis. 

The  impetigo-form  syphilide  may  be  mistaken  for  impetigo  vul- 
garis, as  the  objective  characters  of  the  lesions  are  very  similar.  In  im- 
petigo vulgaris  the  invasion  of  the  eruption  is  more  acute,  and  is  attended 
by  more  or  less  heat  and  itching  of  the  skin.  The  course  of  the  lesions  is  much 
more  rapid  and  the  inflammatory  areola  disappears  when  the  crust  forms. 
From  impetiginous  eczema,  this  syphilide  may  be  distinguished  by  the 
more  sharply  defined  periphery  of  the  lesion,  the  character  of  the  crusts,  and 
the  absence  of  subjective  symptoms.  In  eczema  the  discharge  is  thinner, 
forming  yellowish,  flaky  scales,  and  is  usually  attended  with  intense  subjective 
sensations. 

The  ecthyma-form  syphilide,  sometimes  designated  as  the  large 
pustular  syphilide,  may  be  described  as  a  slight  elevation  of  the  epider- 
mis, containing  a  turbid,  cloudy  fluid,  which  quickly  desiccates,  forming  a 
dark-brown  scab,  beneath  which  ulceration  takes  place  more  or  less  deeply.  The 
superficial  variety  does  not  differ  essentially  from  the  impetigo-form,  except 
in  the  larger  size  of  the  pustules  and  its  predilection  for  the  lower  extremities, 
where  it  is  habitually  seated.  In  the  deep  variety,  the  ulcerations  are  more 
extensive  and  profound,  often  assuming  a  serpiginous  form;  the  edges  of  the 
ulcer  are  punched  out  or  excavated;  and  frequently  the  crust  does  not  com- 
pletely cover  the  ulcer,  but  is  surrounded  by  a  r^ng  of  ulceration.  The  sup- 
puration of  ecthyma  is  usually  profuse  and  of  long  duration.  After  healing, 
there  remains  a  brownish  cicatrix,  which  for  a  long  time  is  surrounded  by  a 
coppery  areola.  The  ecthyma-form  syphilide  is  usually  a  late  mani- 
28 


418  SYPHILIS. 

festatio]),  except  in  iiialigiuint  syphilis  where  it  appears  precociously.  Xot 
infrequently,  by  the  confluence  of  lesions  of  this  type,  large  surfaces  of  ulcera- 
tion are  formed,  accompanied  by  fever  of  a  hectic  character  and  other  severe 
systemic  symptoms. 

This  syphilide  may  be  confounded  with  ecthyma  vulgaris.  The  lesions 
of  the  latter  are  more  furuncular  in  character,  as  well  as  more  painful,  while 
the  suppuration  is  more  superficial,  with  less  tendency  to  form  a  crust.  Vari- 
cose ulcers   of  the  leg  have  also  been  mistaken  for  ecthymatous  ulcers. 

Itupia. — This  is  one  of  the  most  typical  lesions  of  syphilis;  the  presence 
of  characteristic  rupial  crusts  may  be  regarded  as  pathogiiomonic.  The  term  is 
applied  to  the  accumulation  of  dirty -brown,  distinctly  laminated,  conical-shaped 
crusts,  covering  a  flat,  superficial,  ulcerated  surface.  The  crust  is  formed  by 
the  drying  of  the  pustular  contents,  and  as  the  ulcerative  process  extends  at  the 
periphery,  the  crust  is  thickened  by  the  addition  of  successive  layers  from  be- 
neath, each  layer  giving  it  a  broader  base  while,  at  the  same  time,  increasing 
its  height.  In  this  way  the  crust  often  assumes  a  conical  or  oyster-shell  shape, 
and  may  rise  from  half  an  inch  to  an  inch  above  the  surface.  Rupia  may  he 
ranked  as  a  late  secondary  manifestation.  In  cachectic  or  debilitated  persons, 
it  may  develop  within  the  first  six  months,  in  which  case  it  is  usually  associated 
with  other  evidences  of  precocious  syphilis. 

TERTIARY    SYPHILIS. 

Varieties. — The  Gummatous  Syj^hilide. — Under  this  heading  may  also 
be  grouped  the  tubercular  syphilide.  The  tubercle  is  a  small  gumma  devel- 
oped in  the  deeper  layers  of  the  skin.  It  forms  a  small  uodule,  varying  in  size 
from  a  pea  to  a  filbert  or  larger.  The  tubercles  may  be  either  localized  or 
disseminated,  discrete,  or  confluent.  There  are  two  varieties,  the  dry  or 
atrophic  and  the  ulcerative.  In  the  former,  resorption  occurs  without 
ulceration.     In  the  latter  disintegration  and  ulceration  rapidly  take  place. 

The  dry  or  atrophic  variety  may  develop  comparatively  early.  It  may 
be  confined  to  the  face,  shoulders,  or  back  of  arms,  or  it  may  be  disseminated 
over  the  entire  surface  of  the  body.  When  tubercles  are  grouped  upon  the  face 
and  brow,  they  give  rise  to  the  appearance  known  as  ''  leontiasis." 

The  ulcerous  variety  may  be  develo^Ded  at  any  time,  from  the  third 
to  the  fifteenth  or  twentieth  year  of  the  disease  or  even  later.  It  does  not 
differ  essentially  in  form  and  volume  from  the  preceding,  but  the  tumors  un- 
dergo a  process  of  softening  and  breaking-down,  becoming  converted  into  ulcers 
which  are  deeply  excavated  and  crateriform,  wdth  adherent  edges,  and  an  in- 
filtrated border.  The  cavity  left  by  this  loss  of  substance  tends  to  enlarge, 
healing  at  one  point,  extending  in  another,  and  often  assuming  a  horseshoe  or 
kidney  shape. 

Subcutaneous  gummata  are  developed  in  the  subcutaneous  or  sub- 
mucous tissues,  and  in  the  muscles,  bones,  and  internal  organs.     The  nodules 


VARIETIES    OE    TERTIARY    SYPHILIS.  429 

or  tumors  vary  in  size ;  when  deep-seated  or  flattened  tliey  may  cause  no  pro- 
jection above  the  surface.  They  are  at  first  freely  movable,  indolent,  and  in- 
sensitive to  pressure.  Later  on,  they  undergo  a  caseous  degeneration,  become 
adherent  to  the  skin  and  soften  in  the  centre,  so  that  the  morbid  products, 
consisting  of  a  honey-like  material,  are  evacuated.  The  ulcer  thus  left  is  a 
circumscribed  deep  excavation,  with  thickened  edges  and  uneven  floor,  covered 
with  the  debris  of  disintegrated  tissues. 

The  serpiginous  syphilides  may  have  their  origin  in  pustulo-crusta- 
ceous,  tubercular,  or  gummatous  lesions.  The  ulceration,  at  first  circular,  may 
become  reniform  or  gyrate,  spreading  over  large  tracts  of  skin.  Its  extension 
is  determined  by  the  course  of  the  infiltration,  wdiich  advances  at  one  portion 
of  the  circumference,  while  cicatrization  occurs  at  another.  In  the  neighbor- 
hood of  joints  or  of  the  natural  orifices,  the  cicatricial  contraction  may  result 
in  loss  of  motion  or  stenosis. 

The  Vegetating  Syphilide. — This  does  not  constitute  a  distinct  type. 
The  tendency  of  lesions  of  the  papular  type  to  assume  a  condylomatous  char- 
acter under  the  influence  of  various  local  causes  of  irritation  has  already  been 
referred  to  in  connection  with  the  flat  condylomata.  These  papillomatous  pro- 
liferations are  determined  by  a  hyperplasia  of  the  papillae  which  become  elon- 
gated and  prominent,  giving  the  vegetations  a  mammillated  or  verrucose  aspect ; 
they  may  appear  upon  any  of  the  ulcerative  lesions  of  syphilis.  The  vegetating 
syphilide  has  a  predilection  for  regions  of  the  body  provided  with  hairs,  as  tlife 
axillary  folds,  the  genital  regions,  and  the  anal  region.  It  is  also  found  along 
the  naso-jugal  and  naso-labial  folds.  The  vegetations  appear  as  irregular, 
round  protuberances,  of  uneven  size  and  elevation,  and  secreting  a  puriform 
fluid,  which  concretes  into  thin,  yellowish  crusts.  The  removal  of  the  crusts 
reveals  a  red,  rugous  surface,  made  up  of  villous  or  flesh-like  excrescences. 

Diagnosis.- — A  tubercular  syphilide  may  present  a  marked  resemblance 
to  lupus  vulgaris,  especially  when  it  is  localized  in  regions  for  which  lupus 
shows  a  predilection.  The  most  characteristic  feature  is  found  in  the  peripheral 
enlargement  by  the  development  of  new  lesions,  and  their  tendency  to  a 
serpiginous  mode  of  advance.  The  tubercles  of  lupus  are  pinkish,  trans- 
lucent, or  of  an  apple-jelly  color,  and  more  irregular  in  outline.  The  lupus 
process  is,  moreover,  much  slower  in  evolution  than  syphilis.  Lupus  gener- 
ally appears  in  early  life,  before  puberty,  while  acquired  syphilis  is  essen- 
tially a  disease  of  adult  life.  ISTotwithstanding  these  points  of  differentiation, 
it  is  often  difficult  to  decide  whether  we  have  to  deal  with  a  lupus  vulgaris 
or  a  tubercular  syphilide,  especially  when  the  lesion  is  situated  in  the 
region  of  the  nose.  Both  may  occasion  considerable  destruction  of  tissue  and 
consequent  deformity.  In  lupus,  however,  the  ulcerative  process  is  more  apt 
to  destroy  the  alse  and  the  tip  and  cartilaginous  septum,  but  it  does  not  attack 
the  bony  part  of  the  nose.  Syphilitic  ulceration  often  begins  in  the  bony 
structures  and  invades  the  superficial  parts  secondarily. 

Epitheliomatous    ulcers    of  the  nose  and  face  may  be  mistaken  for 


420  SYPHILIS. 

the  tuberciilo-ulcerous  svpliilide.  The  Imrd,  everted  border  of  epi- 
thelioma, the  granulating,  fungous  character  of  the  sore,  and  its  limitation, 
as  a  rule,  to  a  single  lesion,  together  with  the  glandular  enlargements,  the  ac- 
companying cachexia,  and  the  age  at  which  it  is  more  likely  to  occur,  will  serve 
for  purposes  of  differentiation. 

Leprosy. — The  tubercular  syphilide  bears  a  most  deceptive  resemblance 
to  leprosy,  especially  when  the  lesions  are  hypertrophied  and  situated  upon 
the  brow  and  the  lobes  of  the  ears.  The  leprous  neoplasms  are  softer  to  the 
touch  and  larger  in  volume  than  the  syphilitic;  they  occur  upon  an  infiltrated 
base,  with  edema  of  the  skin  and  ganglionic  enlargements.  Anesthesia  is  often 
present  in  a  patch  of  leprous  tubercles  or  its  immediate  neighborhood,  but  absent 
in  syphilis.  At  a  more  advanced  stage  of  leprous  leontiasis  its  features 
are  so  characteristic  as  to  admit  of  no  mistake. 

Ulcerative  gummata  may  also  be  mistaken  for  varicose  ulcer,  but 
the  presence  of  varicose  veins,  and  their  more  frequent  occurrence  in  the  lower 
third  of  the  ankle,  while  the  gummatous  ulcer  has  a  special  predilection  for  the 
upper  and  middle  third  of  the  leg,  should  serve  as  differential  points. 

AFFECTIONS   OF   THE   APPENDAGES   OF   THE   SKIN. 

Syphilis  of  the  Hair. — Loss  of  hair  is  one  of  the  most  common  of  the  sec- 
ondary manifestations  of  syphilis.  It  often  occurs  in  connection  with  the 
syphilitic  fever  which  precedes  the  earlier  eruptions.  It  may  be  limited  to  the 
hairy  scalp  or  it  may  affect  the  hairy  growth  of  the  entire  body.  Alopecia  most 
often  occurs  without  visible  changes  in  the  scalp,  but  during  the  secondary 
stage  a  variety  of  seborrhea  of  the  scalp  often  develops,  differing  in  many 
features  from  ordinary  seborrhea.  Instead  of  increased  secretion,  with  desqua- 
mation, there  is  a  diffused  infiltration  of  the  papillary  layer  and  the  hair  folli- 
cles. Saboraud  classifies  syphilitic  alopecia  as  one  of  the  infectious  alopecias 
due  to  a  toxine,  causing  atrophy  of  the  hair  papillae  and  death  of  the  hair. 

In  syphilitic  alopecia  there  may  be  diffuse  thinning  of  the  hair  of  the  scalp, 
or  it  may  occur  in  patches  which  coalesce,  forming  polycyclic  areas,  which  are 
quite  characteristic.  While  usually  limited  to  the  hairy  scalp,  it  may  affect  the 
eyebrows  and  eyelashes,  and,  more  rarely,  the  hair  of  the  axilla?  and  pudenda. 
The  loss  of  the  hair  is  not  permanent,  except  when  it  continues  to  recur  in 
connection  with  relapsing  cutaneous  manifestations.  The  later  pustular  and 
ulcerative  lesions,  involving  the  cutis  in  its  entire  thickness,  destroy  the  hair 
follicles,  leaving  permanent  bald  spots  upon  the  scalp,  beard,  or  eyebrows. 

Syphilis  of  the  Nails. — The  nail  structures  are  affected  by  syphilis  by  proc- 
esses which  may  affect  both  the  nail  and  the  matrix.  In  syphilitic  onychia 
the  alterations  in  the  nails  are  usually  the  result  of  nutritive  changes.  They 
lose  their  brilliancy,  become  cracked,  and  friable,  while  the  edges  of  the  nail 
are  broken,  terminating  in  an  irregular  or  jagged  margin.  Another  variety  of 
onychia  is  characterized  by  hypertrophy  of  the  nail  substance,  the  nail  some- 
times assuming  a  thickness  of  three  or  four  times  its  normal  size. 


SYPHILIS    OF    THE    ALIMENTARY    SYSTEM.  421 

In  paronychia,  tlie  morbid  process  usually  begins  as  a  papule  devel- 
oped under  the  nail,  or  in  the  ungual  fold  corresponding  to  the  lunula,  or 
else  along  its  lateral  border,  with  more  or  less  swelling  of  the  bed  of  the  nail. 
This  lesion  may  ulcerate  and  give  rise  to  exuberant  granulations  \vhich  crowd 
the  nail  from  its  bed,  resulting  in  its  partial  or  complete  loss.  The  new  nail, 
ultimately  regenerated,  is  apt  to  be  misshapen  or  distorted.  If  the  matrix  be 
entirely  destroyed,  regeneration  of  the  nail  is  not  possible,  and  its  bed  is  occu- 
pied by  a  rough,  amorphous,  horny  substance. 

SYPHILIS   OF   THE   ALIMENTARY   SYSTEM. 

The  Oro-pharyngeal  Cavity. — Syphilis  produces  lesions  of  the  buccal  mucous 
membranes,  analogous  to  those  of  the  skin.  They  are  modified  in  their  forms 
and  jDrocesses  by  the  anatomical  peculiarities  of  the  soil  upon  which  they  de- 
velop. 

Erythema  of  the  mucous  membrane  of  the  mouth  and  throat  often  de- 
velops coincidently  with  or  precedes  the  cutaneous  eruption.  It  consists  of  a 
diffused  redness,  which  may  resemble  catarrhal  angina,  and  which  is  usually 
most  marked  upon  the  arches  of  the  palate  and  tonsils,  or  the  posterior  wall  of 
the  pharynx.     The  tonsils  are  often  red  and  swollen. 

The  mucous  patch  is  the  exclusive  product  of  syphilis,  and  is  the  most 
common  and  characteristic  of  the  secondary  synjptoms.  It  derives  an  additional 
importance  from  the  fact  that  it  is  the  most  common  and  active  source  of 
syphilitic  contagion.  The  mucous  patch  is  a  papule  occurring  upon  the 
mucous  membrane,  usually  superficial  in  character  and  of  short  duration,  but 
reappearing  with  surprising  facility.  Its  tendency  is  to  recur  repeatedly  during 
the  first  two  years,  sometimes  as  late  as  the  fourth  or  fifth  year  of  the  disease 
and  even  later.  The  typical  lesion  is  a  flat  or  slightly  raised  patch,  of  a  cloudy, 
grayish-white  color,  formed  by  the  thickening  of  the  epithelium  over  a  reddened 
infiltrated  surface.  Owing  to  the  warmth  and  moisture  of  the  parts,  the  epi- 
thelium becomes  sodden  and  eroded.  The  patch  may  be  single,  or  it  may  cover 
a  large  surface  formed  by  the  confluence  of  patches. 

Upon  the  buccal  mucous  membrane  and  arches  of  the  palate,  the  patches 
present  a  white  opaline  appearance,  as  if  the  membrane  had  been  touched  with 
a  crayon  of  silver  nitrate.  At  the  tip  and  sides  of  the  tongue,  they  are  not 
rounded  in  outline,  but  are  more  apt  to  occur  in  the  form  of  fissures  or  furrows, 
which  may  be  converted  into  small,  superficial,  ragged  ulcers.  Upon  the  dorsum 
of  the  tongue,  the  lesions  occur  in  the  form  of  circular  or  oval  patches,  the 
surface  being  smooth,  as  if  shaven,  from  loss  of  the  papillse.  Upon  the  tonsils 
the  mucous  patches  are  apt  to  become  disintegrated,  forming  superficial  or  deep 
ulcers.  At  the  angles  of  the  mouth  they  are  often  complicated  with  fissures, 
and  may  be  continuous  with  papules  of  the  cutaneous  surface. 

Diagnosis. — Mucous  patches  are  most  often  confounded  with  aphthae. 
The  latter  lesions,  however,  are  more  yellow  in  e(^lor,  exhibit  a  cup-sluiped  de- 
pression with  a  bright  red  border,  and  are  exceedingly  painful.     The  mucous 


422'  SYPHILIS. 

patcli  is  distingTiislied  by  its  more  superficial  seat,  and  its  grayish-white  color., 
MiTCOUs  patches  may  be  distinguished  from  buccal  herpes  by  a  difference 
in  grouping  and  the  polycyclic  outline  of  the  latter.  Each  lesion  is  surrounded 
by  epithelial  debris  formed  by  the  remains  of  the  purulent  vesicle.  Mer- 
curial stomatitis  may  cause  erosions,  which  may  be  mistaken  for  mucous 
patches.  Their  favorite  seat  is  behind  the  last  molar  tooth  and  upon  the  sides 
of  the  tongue.  The  characteristic  signs  of  mercurial  stomatitis — salivation, 
fetid  breath,  and  red,  spongy  gums — serve  to  differentiate  it  from  mucous 
patches. 

The  tertiary  lesions  of  the  mucous  membranes  consist  of  tubercles 
and  gummatous  deposits,  which  may  be  limited  to  the  mucous  membrane 
or  may  be  implanted  in  the  deeper  tissues.  They  are  usually  limited  and  local- 
ized, but  may  occur  in  the  form  of  a  diffuse  infiltration. 

Superficial  glossitis  is  characterized  by  a  circumscribed  or  diffuse 
thickening  of  the  submucous  cellular  tissue,  resulting  in  a  lamellated  indura- 
tion, presenting  a  red,  glossy  appearance  of  the  surface.  Deep  or  paren- 
chymatous glossitis  invades  the  muscular  tissues  of  the  tongue,  which 
becomes  tumefied  and  sometimes  enormously  hypertrophied.  The  surface  pre- 
sents a  rough  lobulated  appearance,  which  is  quite  pathognomonic.  Ulceration 
may  occur  from  accidental  irritation. 

Gummata  of  the  tongue  may  develop  in  the  mucous,  submucous,  or 
muscular  tissues.  Superficial  gummata  occur  as  small  nodules  beneath 
the  epithelium,  either  singly  or  in  groups.  The  deep  or  parenchymatous 
gummata  are  situated  in  the  muscular  substance  of  the  tongue.  Upon  ulcer- 
ating they  expose  deep  cavities,  with  overhanging,  sloughy  walls.  They  may 
assume  a  serpiginous  form.  Gummatous  patches  of  the  soft  palate  or 
palatine  arch  often  do  irreparable  mischief  by  destroying  the  soft  parts  and 
perforating  the  maxillary  bones.  The  tonsils  and  posterior  walls  of  the  pharynx 
may  be  the  seat  of  tuberculo-ulcerous  gummatous  lesions. 

Leucoplasia,  or  the  so-called  syphilitic  psoriasis  of  the  tongue, 
consists  of  flattened  or  grayish-white  patches,  usually  developed  upon  the  dor- 
sum. They  are  due  to  thickening  and  condensation  of  the  epithelium,  which 
gives  them  a  tough,  leathery  consistence.  They  rarely  become  eroded  or  ulcer- 
ated. Leucoplasia  may  affect  the  sides  of  the  tongue,  but  rarely  the  under 
surface.  Another  favorite  seat  is  inside  the  cheek  at  the  angles  of  the  mouth 
and  lower  lips.  The  duration  of  leucoplasia  is  practically  unlimited ;  in  most 
cases,  it  persists  for  months  or  years,  or  even  during  life.  It  derives  its  chief 
clinical  importance  from  the  fact  that  it  may  undergo  an  epitheliomatous  trans- 
formation, especially  in  persons  who  are  addicted  to  the  excessive  use  of  tobacco. 

Diagnosis. — Tertiary  lesions  of  the  buccal  mucous  membrane  present 
many  points  of  resemblance  to  tubercular  ulceration  and  to  epi- 
thelioma. Tubercular  ulceration  is  more  superficial  than  the  gum- 
matous ulcer,  more  painful,  and  may  occur  on  the  under  surface  of  tlie 
tongue  where  syphilis  is  rare.     It  is  frequently  coexistent  with  tuberculosis  of 


SYPHILIS    OF    THE    ALIMENTARY    SYSTEM.  423 

the  cutaneous  surface.  The  diagnosis  between  syphilis  of  the  tongue  and  epi- 
thelioma is,  clinically,  of  the  highest  importance.  Doubtless  many  cases 
have  been  operated  upon  for  cancer  of  the  tongue,  which  might  have  been 
cured  by  anti-syphilitic  treatment.  The  chief  points  of  distinction  are  the 
more  circumscribed  and  vegetating  character  of  the  epithelioma,  with  hard 
everted  borders,  and  its  localization  on  the  side  of  the  tongue.  It  is  more 
painful  than  syphilis  and  the  neighboring  glands  soon  become  affected.  The 
age  of  the  patient  also  constitutes  a  differential  sign.  In  doubtful  cases,  a 
histological  examination  should  be  made.  Tertiary  lesions  involving  the 
soft  palate  and  tonsils  may  also  present  certain  points  of  resemblance  to  tuber- 
cular ulceration  and  to  cancer. 

The  Esophagus. — Syphilis  of  the  esophagus  is  comparatively  rare.  Stric- 
ture of  the  esophagus  may  result  from  gummatous  infiltration  in  the  submu- 
cous tissues,  followed  by  ulceration.  More  often  the  esophagus  is  secondarily 
involved  from  gummata  in  the  mediastinal  glands,  which  break  through  its 
walls  producing  stenosis  with  dysphagia. 

Stomach.- — Syphilis  of  the  stomach  is  much  more  common  than  was  for- 
merly supposed.  Many  cases  of  chronic  gastritis,  gastric  ulcer,  and,  so-called, 
gastric  cancer,  are  caused  by  syphilis.  It  is  claimed  that  ten  per  cent  of  all 
cases  of  round  ulcer  of  the  stomach  are  of  syphilitic  origin.  Unfortunately, 
there  are  no  absolute  sigTis  which  serve  to  demonstrate  the  nature  of  the  gastric 
lesions,  except  the  test  of  specific  treatment. 

The  Intestine. — Syphilis  of  the  intestine  is  rarely  recognized  in  vivo, 
altliough  numerous  autopsies  have  disclosed  the  existence  of  syphilitic  lesions 
occurring  in  the  form  of  infiltrations  localized  principally  in  the  upper  part 
of  the  intestinal  canal,  which  break  down  and  form  ulcerative  lesions.  The 
scars  which  result  are  flat  and  may  cause  stenosis  of  the  canal.  The  symptoms 
may  simulate  those  of  typhoid.  In  cases  of  ulcerative  enteritis,  of 
obscure  origin,  anti-syphilitic  treatment  should  be  employed,  especially  when 
other  specific  manifestations  are  present. 

The  Rectum. — Syphilitic  ulceration  of  the  rectum  derives  its  chief  clinical 
importance  from  the  frequency  with  which  it  is  followed  by  stricture  of  the 
rectum.  The  cicatricial  contraction  may  proceed  from  an  ulcerative  gumma 
or  more  frequently  from  a  difl^use  gummatous  deposit  in  the  ano-rectal  walls, 
which  degenerates  into  a  retractile  fibrous  tissue. 

The  Liver. — Of  all  internal  organs  of  the  body,  the  liver  is  the  most  fre- 
quently subject  to  syphilitic  changes.  Affections  of  the  liver,  of  a  purely 
congestive  nature,  may  occur  in  the  secondary  stage,  accompanied  with  slight 
enlargement  of  the  organ,  icterus,  and  other  symptoms  of  gastro-intestinal 
derangement.  Of  the  late  lesions  of  the  liver,  two  forms  may  be  distinguished, 
namely,  interstitial  and  gummatous  hepatitis.  These  two  pathological  al- 
terations may  be  associated  and  may  involve  a  portion  of  the  organ  or  the  entire 
liver.  Chronic  interstitial  hepatitis  may  be  either  circumscribed  or 
general.     The  changes  are  first  hypertrophic,  resulting  in  the  irregular,  lobu- 


424  SYPHILIS. 

latecl  condition  characteristic  of  cirrhosis  and  accompanied  -with  emaciation, 
ascites,  etc.  Giinimata  of  the  liver  develop  in  the  shape  of  pea  to  wal- 
nut sized  masses,  sometimes  as  large  as  a  hen's  egg,  -which  are  embedded  in 
the  substance  of  the  organ,  and  said  to  be  more  common  in  the  right  lobe. 
They  undergo  a  condition  of  necrosis  or  caseous  degeneration,  with  an  increase 
of  the  connective  tissue,  and  a  disappearance  of  the  liver  tissue.  In  this  way, 
large  areas  may  disappear,  or  even  the  entire  lobe. 

The  pancreas  is  seldom  affected  except  in  the  hereditary  form  of  the  disease. 

The  splenic  lesions  of  syphilis  are  also  most  characteristically  seen  in  hered- 
itary syphilis. 

SYPHILIS   OF   THE    RESPIRATORY   SYSTEM. 

The  Naso-pharynx. — Tertiary  lesions  of  the  nasal  passages,  involving  the 
cartilages  and  bones  leading  to  necrosis  and  the  jDrodnction  of  the  offensive 
condition  known  as  ozena  syphilitica,  are  common  to  both  acquired  and 
hereditary  syphilis.  Perforation  of  the  septum  may  occur,  with  destruction 
of  the  nasal  bones,  causing  a  flattening  or  falling  in  of  the  bridge  of  the  nose, 
which,  with  a  tilting  up  of  the  apes,  constitutes  a  characteristic  deformity. 
The  ulcerative  process  may  extend  along  the  Eustachian  tube  and  produce  par- 
tial or  complete  deafness.  Xaso-laryngeal  ulcerations,  clue  to  disintegration 
of  gummatous  deposits,  may  give  rise  to  extensive  ulcers,  which  may  sweep 
away  the  epiglottis,  vocal  cords,  and  other  structures  of  the  larynx.  These 
losses  of  structure  are  of  a  deforming  and  permanent  character,  interfering 
with  phonation  and  swallowing. 

The  Trachea. — The  trachea  may  also  be  attacked  by  tertiary  syphilis.  The 
gummatous  infiltration  soon  leads  to  ulceration,  followed  by  perichondritis  and 
necrosis  of  cartilage.  Perforation  of  the  trachea,  with  a  more  or  less  perma- 
nent external  opening,  may  occur.  When  healing  of  these  lesions  takes  place, 
the  cicatricial  contraction  often  causes  stenosis  of  the  trachea,  producing  seri- 
ous dyspnea  or  even  an  alarming  apnea. 

The  bronchi  may  also  be  the  seat  of  tertiary  syphilis.  The  broncliial  lesion 
is  often  bilateral,  and  may  be  followed  by  stenosis  of  the  affected  bronchial 
tubes. 

Lungs. — Syphilis  of  the  lungs  occurs  in  the  form  of  circumscribed  gum- 
mata  or  diffuse  infiltrations.  Recent  advances  in  our  knowledge  teach  that 
syphilis  plays  a  much  more  prominent  role  in  the  causation  of  lung  disease 
than  was  formerly  suspected.  In  many  cases  cicatricial  and  other  changes, 
found  post-mortem  in  the  lungs,  are  recognized  as  due  to  syphilis. 

SYPHILIS   OF   THE  CIRCULATORY   SYSTEM. 

The  Heart. — Our  knowledge  of  syphilis  of  the  heart  is  a  comparatively 
modern  acquisition.  There  are  many  functional  disorders  of  the  heart,  of  a 
neurasthenic  type,  which  are  referred  to  syphilis  as  the  exciting  cause.  Grave 
functional  disorders  of  the  heart  may  be  due  to  changes  in  the  central  nervous 


SYPHILIS    OF    THE    CIKCULATOEY    AND    GENITO-UKINARY    SYSTEMS.  425 

system,  causing  compression  of  or  irritative  changes  in  the  vagus,  but  the  more 
important  pathological  changes,  which  have  been  demonstrated  by  autopsy, 
have  an  anatomical  foundation,  and  are  recognized  as  due  to  tertiary  syphilis. 
ISText  to  rheumatism,  syphilis  must  be  regarded  as  the  chief  factor  in  diseases 
of  the  heart.  Three  distinct  morbid  conditions  are  recogTiized  as  due  to  ter- 
tiary syphilis :    myocarditis,   endocarditis,    and   pericarditis. 

Myocarditis  is  caused  by  small  gummata  in  the  muscular  substance, 
with  secondary  degeneration  of  the  muscular  fibres,  and  the  conversion  of  the 
cell  infiltration  into  fibrous  or  sclerotic  tissue.  The  gummata  in  the  myo- 
cardium are  usually  of  the  miliary  type,  or  else  they  form  nodular  tumors 
which  undergo  a  fatty  or  caseous  degeneration  peculiar  to  syphilitic  products. 
This  destructive  process  may  involve  the  papillary  muscles  and  valves  of  the 
heart. 

Syphilitic  endocarditis  and  pericarditis  are  usually  associated  proc- 
esses, consecutive  to  syphilitic  disease  of  the  myocardium.  Dilatation  of 
the  heart,  without  evidence  of  valvular  lesion,  is  said  to  be  always  suggestive 
of  syphilis.  '    ' 

Angina  Pectoris. — True  angina  pectoris,  caused  by  lesions  of  the  aorta 
or  coronary  arteries  is,  it  is  asserted,  always  due  to  syphilis.  Most  authorities 
assign  a  predominating  influence  to  syphilis  in  the  causation  of  many  diseases 
of  the  heart,  of  obscure  origin.  The  advice  of  Semola  is  to  fight  the  disease 
with  iodides  of  mercury,  even  when  there  are  no  other  manifestations  of  specific 
disease  present. 

Syphilitic  Arteritis. — Since  practically  all  the  pathological  lesions  of 
syphilis  are  caused  by  changes  in  the  blood  vessels,  it  is  not  surprising  that 
syphilitic  arteritis,  atheroma,  arterio-sclerosis,  aortitis,  and  aneurism  should  be 
classified  among  the  manifestations  of  syphilis.  The  syphilitic  origin  of  aneu- 
rism, in  a  proportion  estimated  at  from  fifty  to  seventy  per  cent  or  more,  is 
well  attested. 

SYPHILIS   OF   THE   GENITO-URINARY   SYSTEM. 

Urethra. — Gummata  of  the  urethra  have  been  observed,  as  well  as 
pericavernous   gummata. 

Epididymis. — Syphilis  of  the  epididymis  is  exceedingly  rare.  It  is  usu- 
ally manifested  by  a  small  nodule  or  tumor  the  size  of  a  pea,  or  larger,  situated 
upon  the  globus  major.    This  hard  nodule  undergoes  resorption  spontaneously. 

Syphilitic  Orchitis. — Syphilis  of  the  testicles  is  more  common  than 
is  generally  stated  by  text-book  authorities.  Slight  infiltrations  are  often  over- 
looked, as  they  are  painless  and  do  not  lead  the  patient  to  apply  to  the  surgeon 
for  relief.  Syphilitic  affections  of  the  testis,  while  occasionally  occurring  in  the 
secondary  period,  may  be  properly  classed  among  the  tertiary  lesions. 

Interstitial  Orchitis. — Interstitial  orchitis  may  develop  as  an  inter- 
stitial hyperplasia  or  thickening  of  the  tissues  of  the  organ.  The  organ  becomes 
enlarged,  heavier  and  harder  than  normal,  though,  as  a  rule,  the  process  is  at 


426  SYPHILIS. 

first  indolent  and  painless ;  later  there  may  be  dragging  pains.  The  interstitial 
growth  may  degenerate  into  fibrous  or  sclerotic  tissue.  jS^ot  infrequently,  its 
involution  results  in  obliteration  of  the  seminal  tubes,  atrophy  of  the  testis,  etc. 

Gummatous  orchitis  of  one  or  both  testicles  occurs  in  the  form  of 
nodules  or  tumors  upon  the  surface  or  in  the  body  of  the  testicle,  which  pur- 
sue the  usual  course  of  gummata  in  other  organs.  They  become  adherent  to 
the  skin  and  then  break  down,  with  a  discharge  of  yellowish-white,  fatty,  or 
caseous  material.     The  function  of  the  testicle  is  usually  entirely  destroyed. 

Diagnosis. — The  diagnosis  between  syphilitic  orchitis,  tuberculosis,  and 
cancer  of  the  testicle,  often  presents  difficulties.  Tuberculosis  usuall}^  begins 
in  the  epididymis,  it  is  exceedingly  slow  in  its  evolution,  more  or  less  painful 
on  pressure,  and  often  involves  the  spermatic  cord.  Cancer  of  the  testicle 
is  more  rapid  in  its  evolution,  and  the  fungation  of  the  testis  is  common.  Usu- 
ally there  is  enlargement  of  the  inguinal  and  other  glands.  The  test  of  specific 
treatment  is  an  important  differential  sign. 

Bladder  and  Prostate  Gland. — Syphilitic  lesions  of  the  bladder  and  pros- 
tate are  comparatively  rare,  but  such  cases  have  been  reported  as  cured  by 
specific  treatment. 

Kidneys. — A  possible  etiological  relationship  between  syphilis  and  many  ob- 
scure affections  of  the  kidneys  has  been  recognized  within  the  past  few  years. 
The  frequency  with  which  albumen  is  met  with  in  syphilitic  subjects  is  a  matter 
of  common  observation.  This  was  formerly  attributed  to  the  fact  that  the 
excretion  of  mercury  sets  up  an  irritation  of  the  kidneys,  with  the  production 
of  considerable  quantities  of  albumen,  which  cannot  be  differentiated  from 
albuminuria  due  to  other  causes.  Syphilis  of  the  kidneys  may  occur  as  a 
diffuse  hyperplasia,  in  the  form  of  gnmmy  tumors  or  amyloid  degeneration 
of  the  vessels.  Chronic  syphilitic  nephritis  does  not  differ  essentially 
in  its  symptoms  from  the  interstitial  nephritis  due  to  alcohol  and  other 
causes.  The  pathological  condition  consists  in  fibrous  infiltration  of  the 
kidney  substance,  and  degeneration  of  the  tubes.  Gummatous  deposits  in 
the  kidneys  are  comparatively  rare,  though  they  have  been  found  post- 
mortem in  these  organs.  They  may  be  situated  upon  the  surface  of  the  organ 
or  embedded  in  the  thickness  of  the  cortical  substance.  Their  presence  usually 
gives  rise  to  symptoms  of  parenchymatous  nephritis.  Amyloid  degeneration  is 
another  result  of  sclero-gummatous  changes.  To  what  extent  syphilis  acts  as  a 
factor  in  the  production  of  Bright's  disease  is  not  definitely  determined.  It 
has  been  stated  that  from  twenty-five  to  thirty  per  cent  of  autopsies  show  renal 
lesions,  attributable  to  syphilis,  apart  from  amyloid  disease,  and  that  about 
twenty-five  per  cent  of  syphilitics  die  with  lesions  of  the  kidneys. 

FEMALE  ORGANS  OF  GENERATION. 

Tertiary  syphilis  may  affect  all  parts  of  the  vulva,  producing  hypertrophic 
syphiloma  of  the  lal)ia,  simulating  elephantiasis.  Tertiary  ulceration  of  the 
V7ilva,  causing  various  mutilations  and  deformities,  may  result  from  the  break- 


SYPHILIS   OF    FEMALE    ORGANS   OF    GENERATION   AND    OF    MOTOR  SYSTEM.       427 

ing  down  of  gummatous  infiltrations.  Syphilitic  lesions  of  the  vagina  are  rare, 
except  when  due  to  extension  from  lesions  of  the  vulva.  The  uterus  may  be 
affected  by  syphilis,  in  the  form  of  syphilitic  endometritis  and  parenchymatous 
metritis.  Gummatous  neoplasms  have  also  been  found  in  the  walls  of  the  uterus 
post-mortem.  In  some  instances  they  have  been  confounded  with  uterine 
fibromyomata;  but  their  syphilitic  origin  has  been  proven  by  their  disappear- 
ance under  specific  treatment.  Gummata  have  also  been  found  in  the  uterine 
tubes.    A  condition  of  chronic  fibroid  syphilitic  salpingitis  has  been  described. 

The  ovaries,  like  the  testicles,  may  also  be  affected  by  syphilis,  although 
more  rarely;  on  account  of  their  inaccessible  position,  the  diagnosis  is  not  so 
readily  made. 

The  peritoneum  may  be  affected  by  gummatous  peritonitis,  simulating  gon- 
orrheal peritonitis.  The  pelvis  may  be  the  seat  of  tertiary  syphilis  in  the  form 
of  osseous  gummata  of  the  bones  of  the  pelvis. 

Gummata  of  the  Mammary  Gland. — Gummata  of  the  mammary  gland,  while 
comparatively  rare,  are  sometimes  met  with,  and  may  be  mistaken  for  other 
tumors.  The  gummatous  deposit  in  the  gland  often  breaks  down,  forming  a 
typical  crateriform  ulcer. 

SYPHILIS   OF   THE   MOTOR   SYSTEM. 

Muscles. — Syphilis  may  affect  the  muscles,  tendons,  bones,  or 
joints.  Syphilitic  affections  of  the  muscles  consist  of  diffuse  hyperplasias 
of  the  connective  tissue,  or  the  development  of  gummy  tumors  in  the  sheaths 
or  in  the  substance  of  muscles.  Both  forms  may  result  in  atrophy  of  the  mus- 
cular fibres,  shortening,  contractions,  and  impairment  of  function. 

Tendons. — Inflammation  of  the  tendon  sheaths  may  occur  in  the  sec- 
ondary stage  of  syphilis.  It  usually  affects  the  extensor  tendons  of  the  fingers, 
toes,  biceps,  and,  less  commonly,  the  tendons  about  the  knee-joint,  or  the  tendo 
Achilles. 

Syphilitic  affections  of  the  bursae  are  uncommon.  The  bursa  over  the 
patella  is  most  frequently  involved,  owing  perhaps  to  the  irritation  or  pressure 
to  which  it  is  subjected  in  certain  occupations. 

The  Bones.- — Osseous  lesions  of  syphilis  may  develop  in  the  early  stage, 
although  the  more  characteristic  changes  in  the  bones  occur  in  the  tertiary 
stage.  In  the  early  stage  they  are  limited  to  periosteal  inflammation,  rarely 
periosteal  nodes ;  gummatous  deposits  occur  in  and  beneath  the  periosteum  and 
in  the  bone  substance.  Gummata  may  develop  on  the  skin  or  mucous  mem- 
branes and  involve  the  periosteum  secondarily.  This  is  especially  liable  to 
occur  in  regions  where  the  bones  have  a  thin  covering,  as  over  the  external 
aspect  of  the  tibia,  cranium,  clavicle,  and  so  forth,  and  also  the  bones  of  the 
nose.  The  periosteum  is  destroyed  and  there  is  necrosis  and  exfoliation  of  the 
bone  tissue.  In  other  cases,  the  gummata  are  developed  in  tlie  deeper  tissues  or 
spring  from  the  periosteum.  Suppuration  is  a  comparatively  rare  termination 
of  syphilitic  periostitis.     The  gunmiata  may,  however,  soften  and  break  down, 


428  SYPHILIS. 

the  skin  become  inflamed,  and  the  contents  be  evacuated  by  means  of  one  or 
more  openings  through  which  pieces  of  necrosed  bone  are  often  discharged. 

Periostitis  may  also  occur  in  the  form  of  flattened  or  convex  tumors,  termed 
nodes,  Tvhich  vary  in  size  from  one-haK  to  two  inches  in  diameter,  and  form  a 
considerable  elevation  above  the  surface.  They  may  disappear  under  specific 
treatment  or  become  transformed  into  bony  tissue  and  constitute  exostoses. 

Another  manifestation  of  bone  syphilis  is  osteomyelitis.  It  consists  of 
a  diffuse,  gummatous  infiltration  through  the  cancellous  structure,  resulting  in 
condensation  and  thickening  of  the  bone.  As  a  result  of  the  osseous  lesions, 
there  is  increased  porosity  of  the  bone  and  other  structural  changes,  with  in- 
creased liability  to  fracture  from  trivial  causes. 

The  smaller  long  bones,  like  the  clavicle  and  phalanges,  may  become  rarefied 
by  extensive  gimimatous  infiltrations  and  produce  a  condition  known  as  spina 
ventosa. 

Syphilitic  Dactylitis. — Tertiary  lesions  of  the  gTmimatous  type  may  affect 
the  periosteum,  or  else  be  seated  underneath  the  periosteum  or  in  the  medul- 
lary membrane  of  the  phalanges.  They  may  affect  one  phalanx  or  more.  The 
swelling  is  usually  fusiform  or  acorn-shaped,  hard,  firm,  and  terminating  more 
or  less  aljruptly.  Suppuration  is  rare ;  most  frequently  involution  occurs 
through  resorption  without  disintegration  of  the  giimmatous  tissue.  Atrophy 
and  shortening  of  the  bones,  or  the  formation  of  a  false  joint,  are  not  infre- 
quent results. 

The  Joints. — The  joints  may  be  affected  early  in  syphilis,  giving  rise  to 
arthralgia,  affecting  more  particularly  the  large  joints  of  the  shoulder,  knee, 
and  wrist.  Hydrathrosis  may  also  occur  early.  The  effusion  in  the  joint  may 
be  unaccompanied  with  any  inflammatory  phenomena.  At  a  later  stage  syphilis 
affects  the  synovial  membranes  of  the  joints  by  processes  similar  to  those  affect- 
ing the  periosteum,  resulting  in  syphilitic  arthritis.  Several  large  joints  may 
be  affected,  giving  a  most  deceptive  appearance  to  gonorrheal  arthritis.  Gum- 
matous deposits  in  the  articular  ends  of  the  joints  or  epiphyses,  and  more  rarely, 
the  diaphyses,  occur  in  the  tertiary  stage.  The  gummata  may  break  into  the 
joint  or  form  superficial  sinuses ;  the  usual  result,  however,  is  fibrous  anchylosis. 
It  is  not  readily  amenable  to  specific  treatment,  and  demands  surgical  inter- 
vention. The  bones  of  the  vertebrae  may  also  be  involved  by  ginnmatous 
processes,  simulating  Pott's  disease.  Syphilitic  spondylitis  is  a  comparatively 
rare  manifestation. 

SYPHILIS   OF   THE    EYE   AND    EAR. 

Syphilitic  affections  of  the  eye,  especially  of  the  fundus,  and  paralysis 
of  the  nerves  supplying  the  eye,  are  often  a  manifestation  of  brain 
syphilis,    and  possess  a  grave  significance. 

Cornea. — Syphilitic  affections  of  the  cornea  are  exceedingly  rare  in  ac- 
quired syphilis,  although  quite  common  in  the  hereditary  variety.  Syphilitic 
keratitis  may  manifest  itself  in  either  the  punctate  or  diffuse  form.      Inter- 


SYPHILIS    OF    THE    EYE    AND    EAE.  429 

stitial  keratitis  is  one  of  the  most  common  and  characteristic  manifestations  of 
heredo-syphilis. 

Iritis. — Of  all  specific  affections  of  the  eye  which  come  under  the  observa- 
tion of  the  venereal  specialist,  iritis  is  the  most  significant,  not  only  on 
account  of  its  comparative  frequency,  three  to  four  per  cent  in  acquired  syphilis, 
but  from  its  frequent  unfortunate  results  upon  the  integrity  of  the  vision.  In 
the  tertiary  stage  it  is  comparatively  rare,  usually  developing  in  the  early  sec- 
ondary stage,  about  the  sixth  month  after  infection.  There  are  tv^o  forms  of 
syphilitic  iritis,  the  serous  and  plastic.  In  the  serous  form,  the  eye  pre- 
sents a  pinkish-red  appearance  from  the  injection  of  the  ciliary  vessels,  with 
the  presence  of  small  white  spots  or  deposits  on  the  posterior  surface  of  the 
cornea.  There  is  increased  lachrymation,  accompanied  with  subjective  sensa- 
tions of  supraorbital  pain  and  sensitiveness  to  light.  The  milder  form  usually 
clears  up  under  suitable  treatment,  without  permanent  changes.  Plastic 
iritis  represents  a  more  aggravated  form.  The  congestion  of  the  ciliary  ves- 
sels is  much  more  marked,  the  iris  is  hazy  and  muddy,  and  the  outline  of  the 
pupil  irregular,  presenting  often  a  scalloped  appearance,  due  to  adhesions  with 
the  anterior  capsule  of  the  lens  from  effusions  of  plastic  lymph.  On  account 
of  these  adhesions  and  thickening,  the  pupil  does  not  readily  respond  to  impres- 
sions of  light ;  the  opening  of  the  pupil  may  be  permanently  occluded  from  loss 
of  dilatability.  Gummatous  iritis  is  comparatively  rare.  The  gumma 
may  appear  as  a  small  yellowish-red  neoplasm  springing  from  the  iris,  and  may 
attain  to  a  considerable  size,  entirely  filling  up  the  pupillary  space.  One  or 
both  eyes  may  be  affected. 

Retina  and  Optic  Nerve. — Syphilitic  cyclitis,  choroiditis,  dissem- 
inate choroido-retinitis,  optic  neuritis,  papulitis,  and  the  various 
atrophic  changes  which  may  follow  syphilis  of  the  retina  and  optic  nerve,  come 
more  especially  within  the  province  of  the  ophthalmologist. 

Motor  Affections, — Paralyses  of  the  nerves  supplying  the  eyes  are  almost 
exclusively  due  to  syphilis.  The  diplopia  is  distinguished  accordingly  as  pa- 
ralysis of  an  abductor  or  adductor  muscle  occurs.  Paralysis  of  the  third 
nerve  causes  dropping  of  the  eyelids,  immobility  of  the  globe,  deviation  out- 
ward of  the  external  rectus,  and  dilatation  of  the  pupil.  Seventy-five  per  cent 
of  all  cases  of  ptosis  are  due  to  syphilis.  Paralysis  of  the  sixth  nerve 
produces  deviation  of  the  eye  inward  and  diplopia.  Paralysis  of  the 
fourth  nerve  commonly  occurs  in  connection  with  paralysis  of  other  cranial 
nerves.  The  motor  aff"ections  of  the  eye  may  be  caused  by  a  multiplicity  of 
lesions,  as  gummatous  deposits  in  the  nerves  and  meninges,  or  pressure  from 
gummata,  as  well  as  arterial  changes  at  the  point  of  origin  of  the  cranial  nerves 
or  along  their  course.  They  are  frequently  associated  with  hemiplegia  or  other 
evidences  of  implication  of  the  nervous  system. 

Syphilis  of  the  Ear. — As  before  intimated,  the  ear  is  usually  affected  by 
ulcerations  in  the  naso-pharyngeal  cavity,  leading  to  the  occlusion  of  the  orifices 
of  the  Eustachian  tube ;  or,  the  ulcerative  process  may  involve  the  middle  ear 


430  SYPHILIS. 

from  extension  along  the  course  of  tlie  tube.  The  more  serious  affections  of  the 
auditory  nerve  resulting  in  syphilitic  deafness  and  deaf-mutism,  although  met 
Avitli  ill  the  acquired  form,  are  more  common  in  hereditary  syphilis,  and  are 
often  associated  with  other  dystrophies  peculiar  to  heredo-syphilis.  The 
pathology  is  obscure,  as  the  complete  loss  of  function  of  hearing  may  be  sudden, 
and  occur  without  appreciable  lesion  of  the  auditory  apparatus. 

SYPHILIS   OF   THE    NERVOUS   SYSTEM. 

The  advances  made  in  our  knowledge  of  the  pathology  of  the  nervous  sys- 
tem have  singailarly  amplified  our  conception  of  the  importance  of  the  patho- 
genetic r(51e  played  by  syphilis.  At  the  present  day  syphilis  is  recognized  as 
the  chief  etiological  factor  in  organic  diseases  of  the  nervous  system,  and  one 
of  the  principal  causes  of  dementia. 

Syphilis  of  the  nervous  system  embraces  a  vast  array  of  morbid  manifesta- 
tions. There  is  scarcely  any  functional  or  organic  disease  of  the  brain,  spinal 
cord,  or  nerves  which  may  not  be  produced  by  syphilis  or  its  symptoms  accu- 
rately simulated.  The  restricted  limits  of  this  article  will  not  permit  a  detailed 
description  of  the  varied  and  multiple  manifestations  of  syphilis  of  the  nervous 
system.  Certain  functional  phenomena  met  with  in  the  secondary  stage  of 
syphilis,  such  as  cephalalgia,  sternalgia,  analgesia,  muscular  tremors,  hystero- 
epileptiform  spasms,  etc.,  are  due  to  the  impression  of  the  poison  ujDon  the 
nervous  system.  The  headache  of  syphilis  is  characterized  by  its  intensity,  its 
diffuse  character,  and  its  tendency  to  nocturnal  exacerbation. 

The  more  important  syphilitic  affections  of  the  nerves  belong  essentially  to 
the  tertiary  period.  They  are  usually  met  with  after  the  third  year,  exception- 
ally within  a  few  months  after  the  initial  lesion.  According  to  Fournier's 
statistics,  embracing  seven  thousand  two  hundred  and  forty-nine  tertiary  acci- 
dents, occurring  in  five  thousand  six  hundred  and  ninety-eight  cases,  the  relative 
frequency  of  nerve  lesions  was  shown  by  the  fact  that  there  were  two  thousand 
three  hundred  and  ten  cases  of  nerve  affections,  thirty-one  per  cent,  almost 
one-third,  implicating  the  nervous  system.  Among  these,  there  were  nine  hun- 
dred and  three  cases  of  cerebral  syphilis,  one  hundred  and  ninety-six  cases  of 
medullary  syphilis,  one  hundred  and  sixteen  cases  of  general  paralysis,  and 
nine  hundred  and  forty-three  cases  of  tabes. 

While  cerebral  syphilis  may  appear  within  the  first  year  of  the  in- 
fection, it  increases  in  frequency,  and  attains  its  maximum  in  the  third  year, 
with  a  progressive  decrease  to  the  tenth  year  and  beyond.  Tabes  rarely  ap- 
pears before  the  second  year ;  the  majority  of  cases  develop  from  the  fifth  to 
the  ninth  year.  General  paralysis  is  rare  before  the  fifth  year,  the  larger 
proportion  of  cases  occurring  between  the  sixth  and  twelfth  years,  and  being 
most  marked  in  the  tenth  year. 

The  lesson  to  be  learned  from  these  statistics  is  that  the  worst  effects 
of  syphilis  of  the  nervous  system  develop  from  the  fifth  to 
the   tenth  year   of  the   disease. 


SYPHILIS    OF    THE    NERVOUS    SYSTEM.  431 

Among  the  predisposing  causes  which  determine  the  localization  of  syphilis 
toward  the  nervous  system  may  be  mentioned  hereditary  predisposition  to 
nervous  disease,  nervous  exhaustion,  and  alcoholic  and  venereal  excesses.  It 
is  to  be  noted  that  many  severe  examples  of  brain  syphilis  have  been  found  in 
persons  wdiose  initial  symptoms  were  mild  and  insignificant,  and  who  had  not 
received  specific  treatment.  Fournier  regards  the  absence  of  specific  treatment 
as  the  chief  cause  of  tertiary  manifestations. 

Syphilis  affects  the  nervous  system  in  three  ways : 

(1)  By  causing  disease  of  the  arteries  interfering  with  nerve 
nutrition. 

(2)  By  the  development  of  gummatous  processes  in  the  me- 
ninges,   and  in  the   substance   of   the   nerve. 

(3)  By  compression  of  the  brain,  cord,  and  nerves  from  morbid 
growths  which  may  result  from  exostoses  of  the  cranial  bones  and  spinal  verte- 
brae, by  thickening  of  the  dura  mater,  or  by  narrowing  of  the  bony  canals 
through  which  the  nerves  pass. 

Probably  syphilitic  endo-arteritis  and  peri-arteritis,  caused  by  the  develop- 
ment of  gummatous  nodules  or  infiltrations  of  the  coats  of  the  cerebral  vessels, 
is  the  most  common  cause  of  pathological  alterations  in  the  nerve  substance. 
These  deposits  lead  to  obliteration  of  the  lumen  of  the  vessels  and  consequent 
ischemia  and  circumscribed  softening. 

Of  the  meninges  of  the  brain,  the  dura  mater  is  the  most  frequent  seat  of 
tertiary  lesions,  consisting  of  gummata  or  diffuse  infiltrations  resulting  in 
thickening  and  sclerosis.  Gummata  of  the  dura  mater  may  extend  along  the 
pia  mater  and  invade  the  brain  by  a  direct  growth.  Gummata  of  the  brain 
substance  usually  originate  in  the  pia  mater  or  subarachnoid  space.  They  grow 
towards  the  cortex  of  the  organ,  or  may  penetrate  the  gray  substance,  some- 
times encroaching  upon  the  white  matter.  They  are  most  frequently  seated  in 
the  optic  tract,  the  anterior  lobes,  at  the  surface  of  the  frontal  convolutions, 
the  pons  Varolii,  and  the  base  of  the  brain. 

In  addition  to  the  varied  and  multiple  phenomena  which  characterize  brain 
syphilis,  such  as  monoplegia ;  hemiplegia,  often  bilateral ;  insanity ;  epilepsy, 
etc.,  there  are  various  neuroses  of  the  peripheral  nerves,  more  especially  the 
ulnar  and  sciatic,  which  may  occur  as  a  syphilitic  process.  Such  neuroses  may 
be  limited  to  sensory  disturbances  of  a  more  or  less  painful  character,  and  later 
may  result  in  motor  atrophic  disturbances. 

Spinal-cord. — According  to  Gilles  (de  la  Tourette),  more  than  half  the 
cases  of  diseases  of  the  spinal-cord  are  due  to  syphilis,  exclusive  of  tabes,  which 
considerably  increases  the  proportion.  Syphilitic  processes  may  affect  the  me- 
ninges or  the  interstitial  tissue  of  the  cord  itself,  causing  meningitis  or  myelitis. 
The  two  are  most  commonly  associated  as  meningo-myelitis,  or  the  latter  may  be 
due  to  passive  pressure  from  exostoses  and  caries  of  the  vertebrae.  Paraplegia, 
paralysis  of  the  bladder,  and  sphincter  ani,  ataxic  symptoms,  with  the  group  of 
sensory  disturbances  peculiar  to  tabes,  may  result  from  syphilis  of  the  cord. 


432  SYPHILIS. 

The  etiological  relationship  of  syphilis  to  tabes  dor  sails,  which  has  long 
been  the  occasion  of  livelj  controversy,  may  be  considered  definitely  established 
by  clinical  evidence. 

HEREDITARY    SYPHILIS. 

The  susceptibility  of  syphilis  to  hereditary  transmission  is  a  fundamental 
character  of  the  disease ;  it  may  be  transmitted  to  the  offspring  directly  by  the 
infected  sperm  of  the  father,  or  from  the  infected  ovule  of  the  mother  at  the 
time  of  impregnation,  or  the  infective  principle  may  be  conveyed  through  the 
medium  of  the  utero-placental  circulation  during  the  course  of  pregnancy. 

The  terms  "  congenital "  and  "  hereditary  "  syphilis  are  often  used  indis- 
criminately, but  we  must  recogTiize  the  fact  that  "  congenital "  is  a  broader 
term  than  "  inherited,"  All  that  is  congenital  is  not  inherited,  and  much  that 
is  inherited  is  not  apparent  at  birth.  Properly  speaking,  the  term  hereditary 
syphilis  is  ap-plied  to  cases  of  germinal  infection  through  the 
spermatozoon  or  ovum.  Congenital  syphilis  embraces,  in  addi- 
tion, cases  of  post-conceptional  syphilis  conveyed  through  the 
placental    circulation    in    the    course    of    pregnancy. 

Paternal  Transmission  of  Syphilis. — A  syphilitic  man  may  beget  a  syphilitic 
child,  and  the  mother  remain  exempt  from  signs  of  contamination.  The  pater- 
nal influence  is,  however,  comparatively  restricted  in  its  duration,  being  rarely 
manifest  after  .the  third  or  fourth  year.  As  regards  its  effect  upon  the  fetus, 
the  mortality  of  the  offspring  is  given  as  twenty-eight  per  cent,  and  the  mor- 
bidity as  thirty-seven.  The  question  of  the  paternal  transmission  of  syphilis  to 
the  fetus  without  the  preliminary  infection  of  the  mother  has  been  the  subject 
of  prolonged  controversy ;  clinically,  the  afiirmative  evidence  rests  upton  the  fol- 
lowing gTounds : 

Healthy  children  may  be  born  after  treatment  of  the  father  alone  with 
mercury. 

A  woman  who  has  given  birth  to  syphilitic  children  by  a  syphilitic  father 
may  have  healthy  children  by  another  father. 

Cases  are  on  record  where  a  woman  who  has  given  birth  to  a  syphilitic  child 
has  afterward  acquired  syphilis. 

The  statistics  of  Kassowitz,  Mewes,  Anton,  Hochsinger,  Fournier,  and 
others,  would  seem  to  show  in  the  most  positive  manner  that  in  hundreds  of 
pregnancies  which  terminated  in  abortions,  still  births,  and  syphilitic  children, 
the  mothers  remained  absolutely  healthy  or,  at  least,  exempt  from  all  signs  of 
the  disease.  It  has  been  alleged  that  it  is  impossible  for  the  spirochete  to 
permeate  the  spermatozoon  as  it  is  the  larger  of  the  two  bodies;  but,  on  the 
other  hand,  it  has  been  suggested  that  the  fluid  part  of  the  semen  may  serve 
as  a  vehicle  for  the  spirochete,  or  that  it  may  attach  itself  to  the  sper- 
matozoa as  it  does  to  the  red  blood  corpuscles  (Eilli  and  Vockorodt).  More- 
over, syphilitic  semen  has  been  successfully  inoculated  in  chimpanzees  by 
ISTeisser  and  Tinger. 


MODES    OF    TRANSMISSION    IN    JlKKEDlTxVKY    SYl'lIILIS.  433 

Maternal  Transmission. — A  syjjliilitic  woman  may  bring  forth  a  syphilitic 
child,  the  father  being  perfectly  healthy.  The  transmissive  power  of  the 
mother  is  mnch  more  active  and  prononnced  than  that  of  the  father.  The 
mortality  is  given  as  sixty  per  cent  and  the  morbidity  as  eighty-four 
per  cent.  It  is  also  much  more  prolonged  in  duration,  five  or  six  years,  or 
longer. 

Mixed  Transmission. — When  both  parents  are  syphilitic  at  the  time  of  fecun- 
dation, the  transmissive  power  of  syphilis  acquires  its  maximum  of  intensity, 
causing  a  morbidity  of  ninety-two  per  cent,  with  a  mortality  of  sixty-eight  per 
cent  in  private  practice,  and  eighty-six  per  cent  in  hospital  practice.  Very  often 
the  mortality  is  one  hundred  per  cent,  thus  extinguishing  in  toto  the  posterity 
of  certain  families. 

Syphilis  by  Conception. — The  term  "  conceptional  syphilis  "  is  applied  to  a 
class  of  cases  in  which  a  healthy  mother  is  infected  by  the  syphilized  fetus, 
procreated  by  a  syphilitic  father  who  may,  at  the  time,  be  exempt  from  any 
cutaneous  or  mucous  membrane  manifestations,  and  incapable  himself  of  di- 
rectly communicating  the  disease  to  his  wife.  The  fetus  serves  as  the  inter- 
mediary agent  for  the  transmission  of  the  disease,  by  means  of  the  utero- 
placental circulation,  from  the  father  to  the  mother.  Syphilis  contracted  by  the 
mother  in  this  way  may  be  made  evident  by  positive  signs  of  the  disease  during 
pregnancy  or  later.  In  many  cases  there  is  an  exemption  of  the  skin  and 
mucous  membranes  from  the  more  characteristic  manifestations  of  syphilis, 
and  the  disease  may  not  reveal  itself  until  some  years  later,  ivhen  it  does  so 
by  severe  tertiary  manifestations.  The  relative  mildness  of  conceptional 
syphilis  in  the  mother  has  been  attributed  to  the  more  gradual  syphilizing 
effect  of  the  morbid  germs  and  their  toxines  through  the  placental  walls.  So 
far  as  the  child  is  concerned,  the  influence  of  the  paternal  infection  is  often 
fatal,  resulting  in  its  death  and  premature  expulsion. 

Modifications  in  the  Hereditary  Influence. — The  age  of  the  syphilis,  specific 
treatment,  and  other  circumstances  modify  the  hereditary  influence  of  the 
parents.  Time  exerts  a  marked  attenuating  influence  upon  the  diathesis,  there 
being  a  progressive  enfeeblement  of  the  parental  infection,  as  shown  in  the 
series  of  successful  pregnancies.  Abortions  may  take  place  at  a  more  and  more 
advanced  period  of  fetal  development,  until  finally  they  cease,  and  a  pregnancy 
results  in  a  child  living,  but  syphilitic ;  still  later  in  children  bearing  no  trace 
of  the  disease.  Specific  treatment  may  also  suppress  or  hold  in  temporary  abey- 
ance the  influence  of  the  parents.  A  mother  may  have  one  or  more  abortions 
from  syphilis ;  and  then  if  she  be  subjected  to  active  treatment,  and  pregnancy 
occur,  she  may  bring  forth  a  healthy  child.  If  treatment  be  now  discontinued, 
the  next  pregnancy  may  result  in  a  syphilitic  child.  It  has  been  shown  that 
treatment  of  syphilitic  women  by  mercurial  inunction  reduced  the  number  of 
abortions  more  than  fifty  per  cent.  The  remarkable  effect  of  specific  treatment 
in  correcting  or  neutralizing  the  hereditary  influence  of  syphilis  is,  however, 

subject  to  exception. 
29 


434  SYPHILIS. 

Post-conceptional  Syphilis. — A  woman,  healthy  at  the  date  of  conception,  may 
afterward  contract  syphilis  and  transmit  it  to  her  child  in  utero,  the  father 
being  absolutely  healthy.  The  danger  to  the  child  is  less  the  later  in  pregnancy 
the  infection  occurs.  It  may  be  laid  down  as  a  general  ride  that  contamination 
of  the  fetus  is  not  probable  if  the  maternal  infection  takes  place  after  the 
seventh  month  of  pregnancy.  JSTumerous  statistics  demonstrate  the  pernicious 
influence  of  post-conceptional  syphilis  upon  the  offspring,  when  the  infection 
occurs  between  the  second  and  sixth  months.  The  death  of  the  child  in  utero 
is  the  most  frequent  result. 

Effects  of  Syphilitic  Heredity. — Whether  the  infection  is  communicated 
through  the  sperm  cell,  the  ovule,  or  the  utero-placental  circulation,  the  uter- 
ine death  of  the  fetus  is  the  most  habitual  expression  of  hereditary  syphilis. 
Hereditary  syphilis  is  one  of  the  most  common  causes  of  abortion.  This  may 
be  due  to  changes  taking  place  in  the  placenta.  Certain  pathological  changes 
may  occur  in  the  various  organs  of  the  fetus,  diffuse  or  gummatous  infiltrations 
of  the  bones,  liver,  lungs,  kidneys,  nerve  centres,  and  other  organs.  Hepatic 
lesions  and  lesions  of  the  nerve  centres  constitute  the  most  prolific  cause  of 
death  of  syphilitic  children.  The  syphilitic  child  may  be  born  alive,  with  char- 
acteristic evidences  of  syphilitic  taint.  It  may  be  born  apparently  healthy,  and 
after  a  certain  period,  usually  within  a  fcAv  weeks  or  months,  begin  to  show 
the  stigmata  of  the  parental  disease ;  or  definite  symptoms  may  be  delayed, 
with  especial  liability  to  appear  at  the  period  of  second  dentition,  the  period 
of  puberty,  or  not  until  the  twentieth  or  thirtieth  year  or  later  (late  hered- 
itary syphilis).  Many  lesions,  formerly  referred  to  scrofula  or  tuberculosis 
as  the  generating  cause,  are  now  recognized  as  being  due  to  syphilis.  Evidences 
of  hereditary  syphilis  may  be  manifest  in  symptoms  peculiar  to  syphilis,  and 
which  are  met  with  in  the  acquired  form,  or  by  certain  lesions  which  are  the 
result  of  changes  impressed  upon  the  fetus  in  its  formative  stage,  and  which 
take  on  the  characters  of  arrested  development,  or  degenerations  due  to  perver- 
sions of  nutrition.  These  dystrophies  may  be  limited  to  a  single  organ  or 
system  of  organs,  or  they  may  affect  the  entire  body.  The  spirocheta  pal- 
lida is  found  in  the  greatest  abundance  in  the  heredo-syphilitic  lesions  and  in 
the  internal  viscera,  as  well  as  the  various  lesions  of  the  skin. 

Manifestations  of  Hereditary  Syphilis. — Even  when  the  child  is  born  alive 
and  apparently  healthy,  there  is  usually  an  outbreak  of  specific  eruptions  within 
a  short  period,  ranging  from  the  second  week  to  the  first  or  second  month.  One 
of  the  earliest  and  most  characteristic  manifestations  of  hereditary  syphilis  are 
bullous  lesions  of  the  palms  and  soles.  If  pemphigus  is  present  at  birth,  it 
always  carries  with  it  a  grave  prognosis.  Another  early  manifestation  is 
syphilitic  eoryza,  caused  by  structural  changes  in  the  mucous  membranes 
of  the  air  passages.  This  condition,  known  as  the  "  snuffles,"  is  almost 
pathognomonic  of  inherited  syphilis,  and  carries  with  it  a  certain  significance,  as 
the  obstruction  in  the  nostrils  may  be  so  complete  as  to  prevent  the  child  from 
nursing. 


MANIFESTATIONS    OF    HEEEDITAEY    SYPHILIS.  435 

The  skill  and  nuicons  iiiembrane  nianifestatioiis  of  hereditary  syphilis 
are  similar  to  those  of  the  acquired  form,  as  erythema,  papules,  pus- 
tules, and  tubercles.  On  account  of  the  delicacy  of  the  skin,  papules  are 
quickly  transformed  into  mucous  patches ;  the  moist  or  humid  form  pre- 
dominates. Fissures  and  condylomatous  patches  about  the  mouth,  genitals, 
and  anus  are  much  more  common.  Lesions  of  the  viscera  often  coexist  with 
the  early  cutaneous  manifestations.  Death  most  often  occurs  from  gastro- 
intestinal complications,  from  marasmus,  or  from  cachexia  im- 
pressed upon  the  organism.  The  severity  of  inherited  syjDliilis  is  generally 
exhausted  during  the  first  tv^^o  or  three  years  of  infantile  life.  This  period 
may  mark  a  definite  end  of  the  disease,  or  a  new  train  of  symptoms  may  arise 
in  connection  with  the  second  dentition. 

Hereditary  syphilis  is  further  differentiated  from  the  acquired  form  by 
certain  processes  which  are  its  exclusive  products,  as  peculiar  changes  in 
the  bones,  dental  malformations,  lesions  of  the  eye,  and  of  the 
auditory  apparatus.  The  milk  teeth  of  syphilitic  children  are  apt  to  be 
malformed,  chalky,  and  lost  early.  The  peculiar  dental  changes  characteristic 
of  inherited  syphilis  are  displayed  in  the  permanent  central  incisors,  which 
are  denominated  "  syphilitic  test  teeth."  This  specific  abnormality  consists  in 
the  narrowing  of  the  cutting  border  of  the  teeth,  giving  them  a  peg-shaped  form, 
Avith  a  peculiar  crescentic-shaped  notch  of  the  cutting  edge.  Besides  this,  they 
are  apt  to  be  smaller,  and  converge  towards  each  other  with  a  large  interspace. 
These  dental  abnormalities,  interstitial  or  parenchymatous  keratitis,  and  deaf- 
ness constitute  specific  characteristics  of  inherited  syphilis. 

Independent  of  these  various  lesions  of  particular  structures  and  organs, 
hereditary  syphilis  may  reveal  its  specific  origin  by  certain  characters  expressed 
in  the  physiognomy  and  the  physical  and  mental  development. 
The  newly  born  syphilitic  infant  is  variously  described  as  a  small,  wizened, 
puny,  weakly  creature.  It  has  a  peculiar  aged  appearance,  the  "  old  man  look," 
as  it  is  termed,  which  is  quite  pathognomonic.  The  skin  is  loose  and  flabby, 
the  hair  scanty,  and  the  nails  undeveloped.  The  complexion  is  usually  of  a 
pale,  grayish,  cafe  au  lait  color,  presenting  a  marked  contrast  with  the  pink- 
ish or  rosy  hue  of  health.  The  vital  capacity  of  the  infant  is  materially  im- 
paired. The  influence  of  syphilitic  heredity  is  often  manifest  in  a  latent 
debility  or  inherent  incapacity  for  life.  The  child  succumbs  to  slight  ail- 
ments, often  without  any  apparent  cause.  It  dies  without  reason,  so  to 
speak,  and  the  autopsy  may  reveal  nothing  that  can  be  assigned  as  the  cause 
of  death. 

A  second  type  of  inherited  syphilis  is  characterized  by  slowness  or  re- 
tardation of  development,  the  growth  being  stunted  and  dwarfed.  Such 
children  grow  slowly ;  they  walk,  speak,  and  develop  their  teeth  slowly,  and 
seem  to  remain  long  in  a  state  of  infancy.  The  genital  organs  are  often  rudi- 
mentary and  undeveloped.  The  term  "  infantilism  "  is  employed  to  express  the 
sum  total  of  these  characteristics.      The  intellectual  development  is  likeAvise 


436  SYPHILIS. 

retarded.  The  child  is  apt  to  l3e  slow  in  learning,  either  from  congenital  de- 
ficiency of  the  mind  or  from  a  kind  of  intellectual  asthenia. 

The  malformations  and  dystrophies  of  infantile  syj^hilis  are 
too  numerous  to  describe  in  detail.  The  rachitic  type,  with  large  head,  occu- 
pied hy  hossy  growths,  incurvation  of  the  tibia,  pigeon-breast  malformation  of 
the  thorax,  curved  spine,  deformed  pelvis,  etc.  There  is  another  gToup  of 
dystrophies  which  present  a  marked  deviation  from  the  normal  type,  with  re- 
sulting monstrosities.  Fournier  terms  such  cases  an  exaggeration  or  amplifica- 
tion of  dystroj)hies. 

TRANSMISSION    OF    SYPHILIS    TO    THE    THIRD    GENERATION. 

Clinical  observation  shows  most  conclusively  that  certain  dystrophies  and 
organic  defects  in  the  subjects  of  hereditary  syphilis  may  be  transmitted  to  the 
third  generation.  The  question  which  divides  medical  opinion  is  whether 
heredo-syphilitics  may  transmit  their  disease  in  a  virulent  form,  charged  with 
contagious  activity.  Theoretically,  there  is  nothing  in  this  view  inconsistent 
with  the  most  recent  advance  of  our  knowledge.  Xeisser's  experiments  in  suc- 
cessfully inoculating  monkeys  with  sypliilitic  products  from  the  ovary  and  from 
gummatous  lesions  as  late  as  the  seventeenth  year  of  the  disease,  together  with 
recent  researches  which  show  that  the  spirocheta  pallida  may  be  demon- 
strated in  syphilitic  lesions  at  the  age  of  puberty  or  later,  lend  support  to  this 
view.  We  have  overwhelming  testimony  which  shows  in  the  most  positive  man- 
ner that  the  influence  of  heredo-syphilis  in  determining  abortions,  still-born 
chikb-en,  and  various  dystrophies  is  scarcely  less  marked  than  that  of  acquired 
syphilis.  Fournier  gives  statistics  of  one  hundred  and  sixteen  examples  of 
transmission  to  the  third  generation:  out  of  three  hundred  and  sixty-seven 
pregnancies  there  were  one  hundred  and  eighteen  abortions ;  fifty-nine  early 
births ;  and  one  hundred  and  ninety-t^vo  survivors,  a  mortality  of  forty-eight 
per  cent.  Of  the  survivors  only  thirty-one  appeared  free  from  hereditary 
syphilis.  The  only  element  of  doubt  in  these  cases  is  the  possible  intervention 
of  acquired  syphilis  as  a  factor. 

Positive  evidence  of  the  transmission  of  syphilis  to  the  third  generation 
must  be  based  upon  the  following  conditions : 

(1)  That  the  grandparents,  one  or  both,  had  syphilis. 

(2)  The  hereditary  nature  of  the  syphilis  in  the  third  generation. 

(3)  The  exclusion  of  father  or  mother  having  an  acquired  syphilis. 
Fournier  gives  a  detailed  report  of  eighteen  families  in  which  the  condition 

of  the  gTandparents,  the  parents,  and  descendants  was  distinctly  known.  In 
these  eighteen  families,  there  were  eighty-five  pregnancies  which  terminated  as 
follows :  Twenty-five  abortions,  two  of  which  were  twins ;  thirty  infants  born 
dead,  or  dying  within  a  short  time ;  thirty  living  children.  In  another  table 
he  gives  the  issue  of  forty-six  families  of  heredo-syphilitics :  one  hundred  and 
forty-five  pregnancies,  terminating  in  forty-five  abortions ;  thirty-six  still-born, 


GENERAL    CONSIDEEATIONS    IN    TKEATME^TT.  437 

or  dying  early;  sixty-five  living  children  in  whom  he  found  the  same  kind  of 
dystrophies  as  characterize  hereditary  syphilis  in  the  second  generation. 

While  wc  cannot  conclude  that  syphilis  is  transmitted  in  its  essential  nature 
as  a  virulent  contagious  disease  to  the  third  generation,  yet  it  is  well  known 
that  heredo-syphilis  kills  the  product  of  conception  or  transmits  to  the  survivor 
an  impaired  vitality  with  various  dystrophies,  and  thus  constitutes  a  chief  factor 
in  the  physical,  mental,  and  moral  degeneration  of  the  race.  Erom  an  ex- 
haustive study  of  heredo-syphilis  Tarnowsky  concludes  that  syphilis  has  an  in- 
comparably more  fatal  influence  upon  the  species  and  on  society,  than  on  the 
individual. 

TREATMENT    OF    SYPHILIS. 

The  question  of  the  abortion  of  syphilis  by  destroying  the  virus  at  its  point 
of  entrance  has  already  been  considered.  The  failure  of  abortive  methods  such 
as  excision  or  destructive  cauterization  of  the  initial  lesion  is  jorobably  due  to 
the  rapidity  with  which  the  infection  of  the  system  takes  place  through  the 
lymphatics  and  blood  vessels. 

Remedies. — Two  drugs,  mercury  and  iodide  of  potassium,  consti- 
tute the  basis  of  all  specific  therapeutic  treatment  of  syphilis.  In  the  treatment 
of  eruptions  of  the  secondary  stage,  the  action  of  mercury  is  prompt  and 
curative;  it  abates  their  intensity  and,  hastens  their  involution.  Iodide  of 
potassium  finds  its  special  application  in  the  treatment  of  lesions  of  the  gum- 
matous and  ulcerous  type,  and  the  interstitial  hyperplasias  of  the  viscera ;  the 
rapidity  of  its  action  in  melting  away  gummatous  deposits  and  arresting  ulcer- 
ative processes  is  most  marked.  For  the  lesions  of  the  intermediary  stage,  the 
use  of  these  drugs  in  combination,  constituting  the  so-called  "  mixed  treat- 
ment," is  often  more  efficacious  than  either  alone. 

Object  of  Treatment. — Syphilis  is  intermittent  in  its  manifestations,  and 
after  apparent  cure  the  disease  may  reveal  itself  months  or  years  later  by 
tertiary  manifestations  of  the  gravest  significance.  The  object  of  treatment 
then  is  not  simply  to  cure  existing  manifestations,  but  to  prevent  their  develop- 
ment in  the  future.  Clinical  experience  shows  that  the  active  use  of  mercury 
through  the  first  two  or  three  years  of  syphilis  constitutes  the  most  reliable  safe- 
a:uard  against  tertiarv  manifestations. 

Fournier  insists  that  a  sufficient  mercurial  treatment  affords  a  preventive 
guarantee,  if  not  complete,  at  least  relative,  against  tabes  and  general 
paralysis.  His  careful  study  of  six  hundred  and  fifty-five  cases  shows  that 
tabes  or  general  paralysis  followed  in  only  5.56  per  cent  of  cases  which  had 
been  subjected  to  a  careful  mercurial  treatment  for  three  years  or  longer ;  while 
95  per  cent,  or  to  be  more  accurate  94.44  per  cent,  succumbed  to  short  and  in- 
sufficient treatments. 

General  Considerations  in  the  Administration  of  Mercury. — There  are  certain 
principles  ^^ertaining  to  the  use  of  mercury,  in  the  treatment  of  syphilis, 
which  clinical  experience   has  established   as   fixed  and   definite.      Mercury 


438  SYPHILIS. 

should  be  given  in  moderate  but  efficacious  doses,  and  not  pushed  beyond  tho 
production  of  its  primary  physiological  effects.  The  production  of  saliva- 
tion, and  other  toxic  effects  of  large  doses  of  the  drug,  is  positively  pernicious. 
Its  influence  upon  the  eruption,  and  the  toleration  of  the  patient's  system, 
should  be  the  measure  of  the  dose.  The  two  principal  plans  of  administering 
mercury  are  known  as  the  "  tonic  treatment  "  Ijy  the  continuous  use  of  small 
doses  and  the  method  of  ''  intermittent  treatments."  In  laying  down  rules  for 
the  treatment  of  syphilis,  the  most  practical  questions  are :  when  should  specific 
treatment  be  commenced;  how  should  it  be  given;  what  should  be  its  duration? 

The  projDer  time  for  beginning  specific  treatment  is  when  the 
diagnosis  is  positively  established.  Since,  in  the  large  proportion  of  cases,  the 
appearance  of  the  eruption  constitutes  the  necessary  confirmation  of  the  diag- 
nosis, most  authorities  counsel  delay  until  the  appearance  of  secondary  mani- 
festations. 

An  undue  importance  has,  perhaps,  been  assigned  to  the  choice  of  the 
method  of  giving  mercury.  Its  effects  are  much  the  same  through  what- 
ever channel  of  entrance  it  is  introduced  into  the  system.  The  choice  of  the 
method  should  not  be  determined  by  rule  or  theory,  but  governed  by  indica- 
tions furnished  by  the  condition  of  the  patient,  the  stage  of  his  disease,  and  his 
morbid  aptitudes.  For  example,  a  patient  with  dyspepsia,  a  weak,  irritable 
stomach,  or  a  tendency  to  diarrhea,  should  not  be  subjected  to  the  ingestion  of  a 
drug  which  will  still  further  derange  his  digestive  functions. 

Ingestion. — This  is,  perhaps,  the  most  convenient  method  of  giving  mer- 
cury, and  is  commonly  employed  in  this  country,  France,  and  England.  It 
may  be  administered  by  the  mouth  in  the  form  of  a  pill  or  mixture.  The 
chief  mercurial  preparations  employed  are  the  protoiodide  pills,  each 
containing  one  centigramme  (about  one-sixth  of  a  grain),  from  one  to  three 
of  which  may  be  given  three  times  a  day,  after  eating;  Hydrargyrum 
cum  creta,  in  tablet  or  pill  form,  one  to  two  grains,  three  times  a  day. 
Dupuytren's  pills  and  the  ordinary  blue  pill,  are  also  used  in  the 
treatment  of  syphilis.  My  own  preference  is  for  the  protoiodide.  If  this 
preparation  should  be  foim.d  objectionable  on  account  of  its  tendency  to  pro- 
duce gastro-intestinal  derangement,  it  may  be  combined  with  opium ;  or  some 
other  preparation  of  mercury,  such  as  the  t annate  or  salicylate,  may  be 
substituted.  Mercury  may  be  given  in  solution,  in  combination  with  bitter 
infusions,  or  the  tincture  of  iron.  Among  the  standard  prej^arations  or 
solutions,  the  liquor  of  Van  Swieten  may  be  mentioned,  or  mercury 
combined  with  iodide  in  the  syrup  of  Gibert,  which  is  a  favorite  pre- 
scription in  the  Paris  hospitals. 

Inunction. — This  is  the  oldest  method  of  administering  mercury  in  the 
treatment  of  syphilis.  It  still  retains  its  popularity,  especially  in  Germany, 
where  it  is  regarded  as  the  sovereign  method.  It  consists  in  making  frictions 
over  different  regions  of  the  body  with  mercury  or  one  of  its  salts  combined 
with  a  fatty  substance,  us  in  the  blue  ointment,  (U*  some  one  of  the  numerous 


HYPODEEMIC    METHOD    OF    TREATMENT.  439 

modifications  which  have  been  made  of  it.  This  method  is  serviceable  in 
securing  the  rapid  action  of  mercury.  It  has  the  decided  disadvantage  of 
uncleanliness,  and  of  causing  cutaneous  irritations.  The  skin  of  many  patients 
is  so  exceedingly  sensitive  to  external  irritation,  that  the  inunction  method  in 
such  cases  is  impracticable.  Inunction  finds  its  special  application  when  we 
wish  to  secure  the  intensive  action  of  the  drug,  in  the  case  of  children,  of 
pregnant  women,  and  in  all  cases  where  gastro-intestinal  irritation  is  liable  to 
follow  its  ingestion  by  the  stomach.  The  technic  used  in  inunctions  is  too  well 
kno^^Ti  to  justify  its  description  in  detail. 

Hypodermic  Method. — This  is  a  comparatively  recent  innovation  upon 
older  and  established  methods.  It  has  the  advantages  of  greater  convenience, 
combined  with  scientific  accuracy.  It  is  also  claimed  that  the  action  of  the 
drug  is  more  promptly  curative  when  given  hypodermically ;  that  the  maximum 
effect  is  obtained  with  a  minimum  dose;  and  that  it  rarely  causes  salivation, 
or  irritation  of  the  stomach  or  intestines. 

Two  classes  of  mercurial  preparations  are  employed  for  subcutaneous  injec- 
tion: soluble  injections,  which  are  introduced  every  day  or  every  other  day, 
and  are  promptly  eliminated;  and  insoluble  injections,  which  are  gradually 
absorbed  and  are  given,  on  an  average,  once  a  week.  The  principal  soluble 
preparations  used  are:  the  bichloride,  the  biniodide,  the  benzoate, 
and  more  recently,  the  cacodylate,  the  salicylo-arsenate,  etc.  The 
soluble  injections  are  usually  painful,  and  the  necessity  for  their  daily  repeti- 
tion renders  them  impracticable  in  most  cases.  The  chief  insoluble  prepa- 
rations are:  the  gray  oil,  calomel,  and  the  salicylate  of  mercury. 
These  are  absorbed  slowly,  and  only  require  repetition  at  several  days'  in- 
terval. The  gray  oil  and  calomel  injections,  although  efficient,  are  apt 
to  be  painful,  and  not  infrequently  give  rise  to  indurations,  nodosities,  and 
abscesses  at  the  seat  of  puncture.  ISTo  such  objection  applies  to  the  intra- 
muscular injection  of  the  salicylate  of  mercury  combined  with  ben- 
zoinol,  in  the  proportion  of  twenty-four  grains  to  the  ounce.  Injections  of 
this  preparation  are  comparatively  painless,  and  seldom  give  rise  to  local 
irritation.  '' 

The  site  usually  chosen  for  the  intramuscular  injections  of  mercury  is  the 
upper  inner  third  of  the  buttock,  since  the  surface  of  this  region  is  little  sen- 
sitive, and  there  are  no  vessels  or  nerves  of  importance  to  be  avoided.  The 
injections  should  be  made  with  antiseptic  precautions,  and  should  be  inserted 
deeply  into  the  muscle,  the  buttocks  being  used  alternately.  The  ordinary 
dose  of  the  insoluble  preparation  would  represent  from  three-fourths  to  one 
and  a  half  grains  of  mercury.  Intramuscular  injections  of  mercury  have  a 
special  value  in  severe  lesions  of  the  tertiary  type,  especially  in  cases  where 
the  patient  has  taken  an  insufficient  mercurial  treatment  in  the  early  stage. 
It  often  causes  the  disappearance  of  lesions  whicli  do  not  yield  to  iodide  of 
potassium,    or  to  the  use  of  the  drug  given  by  the  moutli. 

The    dermo-pulmonary    method  of  fumigations  of  mercury  is  seldom 


440  SYPHILIS. 

employed  in  the  ordinarj  treatment  of  syphilis.  Intra-venons  injections 
of  mercury  have  not  justified  the  claims  of  their  originator.  The  serum- 
therapy  of  syjDhilis,  whatever  may  be  its  future,  has  no  scientific  basis 
at  the  present  day. 

The  iodide  of  potassium  is  the  remedy  par  excellence  for  the  tertiary 
manifestations  of  syphilis.  It  is  also  valuable  in  the  early  stage  for  the  head- 
ache and  osteocopic  pains,  and  in  the  treatment  of  pustular  lesions,  which  show 
a  tendency  to  ulcerative  action.  The  various  tertiary  affections  of  the  bones, 
the  gummato-ulcerous  and  specific  lesions  of  the  viscera  and  nerves,  come  within 
the  range  of  its  curative  action.  Iodide  of  potassium  is  not  so  toxic  in  its 
effects  as  mercury,  and  may  be  given  with  impunity.  There  is,  however,  a 
mistake  on  the  part  of  many  specialists,  in  giving  enormous  doses  of  iodide 
of  potassium,  as  large  as  one-half  to  one  ounce  per  diem.  These  massive  doses 
are  not  necessary  in  order  to  develop  the  full  therapeutic  efficacy  of  the  drug. 

In  resorting  to  mixed  treatment,  the  biniodide  of  mercury  is 
the  preparation  most  generally  employed  in  combination  with  iodide  of  potas- 
sium. When  the  latter  is  given  alone,  the  most  convenient  mode  of  adminis- 
tration is  in  the  form  of  a  saturated  solution.  It  may  be  associated  with  a 
bitter  infusion,  with  a  view  of  assisting  digestion,  or  with  various  syrups  to 
render  it  more  palatable.  An  admirable  combination  is  its  admixture  with  the 
elixir   of   lacto-peptin,    one  to  four. 

The  duration  of  the  treatment  of  syphilis  is  usually  from  three  to 
four  years.  Under  certain  conditions,  complementary  or  supplemental  treat- 
ments are  given  at  intervals  during  five  or  six  years,  or  longer. 

While  the  value  of  this  general  scheme  of  treating  syphilis  has  been  estab- 
lished by  experience,  it  is  to  be  understood  that  no  rules  of  treatment  can  be 
formulated  which  shall  apply  to  all  cases.  The  treatment  of  syphilis  cannot 
be  reduced  to  the  terms  of  a  mathematical  formula — so  many  months  of  mer- 
cury followed  by  so  many  months  of  iodide  of  potassium.  There  is  no  class 
of  diseases  which  so  well  illustrates  the  principle  that  uniformity  of  practice 
is  not  a  good  practice.  The  treatment  must  be  modified  and  adapted  to  the 
quality  or  type  of  the  disease.  Many  conditions  relating  to  the  constitution 
of  the  individual,  his  inherited  or  acquired  predispositions,  and  his  habits  of 
life,  must  be  taken  into  consideration.  The  indications  are  to  treat  the  pa- 
tient as  well  as '  the  disease.  Unfortunately,  all  men  are  not  equal  before 
syphilis.  Common  observation  shows  an  immense  difference  in  the  character 
of  syphilis  in  different  individuals,  in  the  multiplicity,  severity,  succession,  and 
duration  of  its  manifestations.  While,  in  the  majority  of  cases,  active  treat- 
ment during  the  secondary  stage  marks  the  definitive  end  of  the  disease,  yet 
long-continued  observation  shows  that  active  and  prolonged  treatment  does  not 
afford  an  absolute  guarantee  against  tertiary  manifestations.  Independent  of 
what  are  termed  "  factors  of  gravity "  of  syphilis,  there  are  certain  patho- 
logical predispositions  which  contribute  toward  the  perpetuation  of  the  syph- 
ilitic process   in   certain   individuals.      The  neuropathic   predisposition   which 


FOUKWIEK  S    VIEWS    ON    TKEATMEKT    OF    SYPHILIS.  441 

comes  from  the  hereditary  make-uj)  of  the  individual,  or  which  may  he  acquired 
by  weakening  of  the  nervous  system  from  overstrain,  worry,  or  excesses  and 
dissipation,  constitute  a  powerful  predisposing  cause  of  nerve  syphilis.  Such 
individuals  are  predestined,  so  to  speak,  by  virtue  of  their  neurotic  heritage, 
or  acquired  predisposition,  to  the  serious  dangers  which  come  from  syphilis  of 
the  nervous  system.  Such  cases  should  be  subjected  to  an  anti-nervine  as  well 
as  an  anti-syphilitic  treatment,  and  this  treatment  should  be  especially 
intensified  at  periods  when  the  cerebral  manifestations  of  the  disease  have  their 
habitual  development.  Fournier  is  a  strong  advocate  of  the  chronic  inter- 
mitted method  of  treating  syphilis.  He  believes  that  mercury  acts  as  a  sort 
of  vaccine  against  the  syphilitic  virus,  and  that,  like  vaccination,  its  protective 
influence  is  exhausted  or  attenuated  by  time.  He  insists,  therefore,  that  in 
certain  types  of  cases,  there  should  be  a  series  of  cures  or  repeated  mercurial 
re-vaccinations,  in  order  to  suppress  the  tendency  to  these  explosive  accidents. 
And  further,  that  these  treatments  should  be  approached  as  nearly  as  possible 
to  the  periods  of  the  greatest  imminence  of  nerve  syphilis,  that  is,  from  the 
fifth  to  the  tenth  year. 

In  his  latest  brochure  ("  Pour  en  Guerir,"  Paris,  1907)  Fournier  declares 
that  three  conditions  are  necessary  for  the  cure  of  syphilis,  namely:  (1)  Good 
health,  (2)  good  hygiene,  and  (3)  good  treatment.  In  all  cases,  the  general 
health  of  the  patient  should  be  built  up,  and  his  power  of  resistance  against 
the  disease  strengthened.  In  neuropathic  individuals  especially,  the  nervous 
system  should  be  toned  up,  and  all  debilitating  and  depressing  influences,  such 
as  nervous  overstrain,  excesses  of  all  kinds,  and  alcoholic  and  venereal  excesses 
particularly,  should  be  avoided.  These  hygienic  measures  are  of  the  highest 
possible  value,  and  are  scarcely  subordinate  in  importance  to  specific  treatment. 

The  hygiene  of  the  mouth  is  of  especial  importance,  even  before  specific 
treatment  is  begun.  A  systematic  supervision  of  the  mouth  may  be  considered 
an  absolute  necessity  during  the  entire  course  of  mercurial  treatment,  not  only 
with  a  view  of  preventing  mercurial  stomatitis,  but  also  of  preventing  specific 
manifestations  which  are  the  direct  result  of  local  irritation.      The  irritating 

o 

influence  of  tobacco  upon  the  mucous  membrane  of  the  mouth  and  throat, 
as  well  as  its  depressing  influence  upon  the  vital  functions,  render  it  especially 
objectionable.  Tobacco  should  be  absolutely  interdicted  during  the  first  year 
of  the  disease,  and  longer,  if  there  is  a  tendency  to  localization  of  the  disease 
in  the  mouth,  in  the  shape  of  mucous  patches  or  leucoplasia.  The  importance 
of  this  is  emphasized  by  the  consideration  of  the  fact  that  leucoplasia  is 
the  almost  habitual  precursor  of  cancer  of  the  tongue.  In  Fournier's  statistics 
of  one  hundred  and  ten  cases  of  lingual  cancer,  seen  in  private  practice,  one 
hundred  and  seven  occurred  in  syphilitic  smokers  who  were,  for  the  most  part, 
heavy  smokers.  He  declares  that  syphilis  alone  does  not  produce  cancer.  It 
requires  for  its  genesis  a  collaborator,  and  this  collaborator  is  tobacco.  The 
influence  of  alcohol  in  provoking  and  aggravating  the  manifestations  of 
syphilis  is  too  well  known  to  require  eiupliasis. 


442  SYPHILIS. 

Local  Treatment. — Experience  ^vitll  tlie  dermic  method  has  shown  that 
merciirv  causes  the  lesions  of  syphilis  to  disappear  more  rapidly  in  the  imme- 
diate vicinity  of  its  application  than  upon  remote  parts  of  the  body.  The 
superficial  and  generalized  eruptions  of  the  secondary  stage  are 
usually  promptly  repressed  by  the  internal  use  of  mercury  alone.  When  a 
papular  eruption  is  situated  upon  an  exposed  part,  as  the  nose  or  the  face,  its 
involution  may  be  hastened  by  the  use  of  ointment  of  ammoniated 
mercury  or  an  ointment  of  the  oleate  of  mercury,  or  a  weak 
solution  of  bichloride  in  glycerin.  The  unsightly  pigmentations 
upon  the  face  and  forehead,  which  often  remain  some  time  after  the  lesions 
have  disappeared,  clear  up  more  rapidly  under  the  influence  of  a  bichloride 
lotion  or  ointment.  Mucous  patches  of  the  mouth  and  throat 
disappear  more  readily  under  the  influence  of  local  treatment,  than  from  the 
internal  use  of  mercury.  The  patches  may  be  touched  with  nitrate  of 
silver,  the  solid  stick,  or  in  solution,  or  they  may  be  painted  with  a  solution 
of  chromic  acid,  fifteen  to  forty  grains  to  the  ounce.  For  leucoplasia 
and  other  sclerotic  conditions  of  the  tongue  and  cheeks,  the  acid  nitrate 
of   mercury   may  be  used  with  advantage. 

Affections  of  the  nasal  mucous  membranes  are  best  treated  by 
frequently  cleansing  the  passages  with  Dobell's  solution  or  other  anti- 
septic douches ;  afterwards  calomel  or  aristol  may  be  thrown  up  by  means 
of  a  powder  projector.  In  the  treatment  of  moist  papules,  and  mucous 
patches  of  the  integument,  it  is  well  to  keep  the  surface  well  powdered 
with  calomel  and  oxide  of  zinc  and  separated  from  contact  by  the 
interposition  of  dry  lint  or  absorbent  cotton.  The  condylomata  about 
the  scrotum  or  vulva,  or  around  the  anus,  should  be  frequently 
cleansed  with  a  weak  Labarraque  solution  (for  formula  see  Chap.  XIII,  p. 
324).  A  powder  of  salicylic  acid,  10  grains,  boracic  acid,  30  gTains,  and  calo- 
mel, 1  drachm,  will  cause  these  lesions  to  rapidly  melt  away. 

For  the  scaly  eruptions  upon  the  palms  and  soles,  which  are 
almost  always  characterized  by  obstinacy  to  constitutional  treatment,  white 
precipitate  or  blue  ointment  may  be  applied,  often  with  good  results. 
The  diachylon  plaster  or  the  emplastrum  hydrargyri,  constitutes 
a  most  excellent  application  for  the  so-called  "  syphilitic  psoriasis  "  of  the  palms 
and  soles. 

For  the  pustulo-crustaceous  and  ulcerous  lesions,  mercurial 
ointments  or  a  mercurial  plaster  will  be  found  serviceable.  In  the 
deep  ulcerative  lesions,  which  are  especially  apt  to  occur  on  the  leg, 
strapping  with  the  emplastrum  de  Vigo,  and  an  occasional  touching  up  of 
the  indolent  granulating  surfaces  with  nitrate  of  silver,  materially  hastens 
the  cure.  The  painful  periosteal  swellings  and  osteocopic  pains  may 
be  relieved  by  painting  with  tincture  of  iodine  or  the  application  of 
mercurial  plaster.  "When  the  joints  are  affected,  counterirritants  and 
immobilization  are  indicated.     Often  surgical  intervention  is  required. 


TREATMENT    OF    INFANTILE    SYPHILIS.  443 

For  syphilitic  orchitis,  a  suspensory  bandage  to  relieve  the  weight  of 
the  testicles,  and  frictions  with  oleate  of  mercury  over  the  scrotum,  give 
relief. 

Treatment  of  Infantile  Syphilis. — The  treatment  of  infantile  syphilis, 
whether  hereditary  or  acquired,  requires  certain  modifications  in  the  treatment 
best  adapted  for  adults.  On  account  of  its  tendency  to  produce  gastro-intestinal 
irritation,  the  internal  administration  of  mercury  is,  as  a  rule,  contraindi- 
cated.  In  some  children  the  drug  does  not  develop  intestinal  irritation,  and  it 
may  be  given  in  the  form  of  mercury  with  chalk. 

In  the  majority  of  cases,  however,  inunction  with  blue  ointment,  the 
oleate  of  mercury  or  mercurial  baths,  are  used  in  the  treatment  of 
infantile  syphilis.  The  inunctions  may  be  made  over  different  regions  of  the 
body,  a  different  surface  being  selected  for  each  application.  A  convenient 
method  of  inunction  is  by  smearing  the  child's  flannel  band  with  blue  oint- 
ment.     The  movements  of  the  child  will  be  sufficient  to  cause  its  absorption. 

On  account  of  the  delicacy  of  the  child's  skin,  syphilitic  lesions  are  apt  to 
assume  the  moist  form.  The  child  should  be  frequently  bathed,  and  the  lesions 
dusted  with  protective  powders.  Mercurial  baths,  prepared  by  the  addi- 
tion of  a  weak  alcoholic  solution  of  the  sublimate  to  the  ordinary  bath, 
with  or  without  chloride  of  ammonium,  is  a  cleanly  and  convenient 
method  of  employing  mercury.  The  existence  of  large  abraded  or  ulcerated 
surfaces  would  constitute  a  contraindication.  Many  authorities  recommend 
subcutaneous  injections  of  mercury  in  the  treatment  of  infantile  syphilis. 

For  the  vegetating  condylomata  around  the  genitalia  and  anus,  dusting 
with  equal  parts  of  oxide  of  zinc  and  calomel  constitutes  the  most 
efficient  local  treatment.  ' 

The  treatment  of  hereditary  syphilis  by  the  administration  of  specific 
treatment  to  the  mother  or  wet-nurse  during  the  period  of  lac- 
tation is  of  doubtful  value.  It  is  questionable  whether  the  milk  is 
materially  modified  by  the  action  of  mercury  or  whether  the  mercurialized 
milk  of  the  mother  exercises  a  curative  inffuence  upon  the  syphilis  of  the 
child.  Iodide  of  potassium  finds  its  special  application  in  the  treatment  of 
the  late  or  tardy  manifestations  of  hereditary  syphilis  which  develop  at  the 
period  of  second  dentition,  of  early  adolescence,  or  later. 

SYPHILIS    AND    MARRIAGE. 

Two  fundamental  characters,  contagiousness  and  susceptibility  of  hered- 
itary transmission,  give  to  syphilis  an  altogether  special  importance  in  relation 
to  marriage.  The  statement  has  been  made  that  syphilis  constitutes  a  far 
greater  danger  to  society  and  the  race  than  to  the  individual.  The  chief  sig- 
nificance of  syphilis  as  a  racial  danger  comes  from  its  hereditary  effects.  The 
vast  array  of  morbid  phenomena,  dystrophies,  and  degenerations,  which  make 
up  the  pathology  of  hereditary  syphilis  has  its  chief  source  in  marriage.     In 


444  SYPHILIS, 

addition,  hereditary  syphilis  undoubtedly  creates  a  terrain  or  soil  favorable 
for  the  reception  and  germination  of  tubercle  bacilli  and  perhaps  other 
bacilli.  It  does  this  by  impoverishing  the  organism  and  diminishing  the 
capacity  of  resistance  against  microbic  invasion. 

Syphilis  is  the  only  disease  transmitted  in  full  virulence  to  the  offspring, 
killing  them  outright  or  blighting  their  normal  development.  From  the  view- 
point of  race  perpetuation  syphilis  is  antagonistic  to  all  that  the  family  repre- 
sents in  our  social  system.  The  social  aim  of  marriage  is  not  simply  the  pro- 
creation of  children,  but  of  children  born  in  conditions  of  vitality,  health,  and 
physical  vigor.  The  effect  of  syphilis  is  to  so  vitiate  the  procreative  process 
as  to  produce  abortions,  or  else  a  race  of  inferior  beings,  endowed  with  defects 
and  infirmities  and  unfit  for  the  struggle  of  life.  It  is  this  pernicious  effect 
of  syphilis  upon  the  offspring  which  gives  to  the  disease  a  dominant  influence 
as  a  factor  in  the  degeneration  and  depopulation  of  the  race. 

Apart  from  its  hereditary  risks,  the  important  relations  of  syphilis  with 
marriage  are  emphasized  by  its  quality  of  contagiousness.  Owing  to  its  multi- 
tudinous modes  of  contagion,  syphilis,  introduced  into  marriage,  often  becomes 
the  origin  of  numerous  innocent  infections  which  are  communicated  in  the 
ordinary  relations  of  family  and  social  life. 

There  is  no  department  of  preventive  medicine  which  is  more  important 
or  yields  results  of  higher  value  to  the  welfare  of  the  family  and  society  than 
the  safeguarding  of  marriage  from  syphilitic  infection.  The  sanitary  office 
of  the  physician  is:  (1)  To  prevent  the  introduction  of  syphilis  into  mar- 
riage; (2)  when  syphilis  has  already  been  introduced,  to  circumscribe  or  limit 
its  effects.  The  intelligent  exercise  of  this  protective  duty  demands  not  only 
professional  knowledge,  but  wisdom,  tact,  and  experience,  especially  in  deal- 
ing with  the  numerous  and  complicated  situations  which  are  created  by  the 
introduction  of  syphilis  into  marriage. 

Before  Marriage. — There  are  certain  practical  questions  which  have  an 
important  bearing  upon  the  intelligent  discharge  of  the  responsible  duty  of 
shielding  the  innocent  from  infection. 

Should  the  syphilitic  man  marry  ?  That  most  men  have  some 
conception  of  the  contagious  and  hereditary  influence  of  the  disease,  is  evident 
from  the  question  so  frequently  propounded  to  the  physician  by  the  man  who 
has  contracted  syphilis — Can   I   marry    and    have   healthy   children? 

To  this  question  the  physician  is  justified,  in  the  large  proportion  of  cases, 
in  giving  a  reassuring  response,  exception  being  made  of  a  class  of  cases  pres- 
ently to  be  referred  to,  in  which  the  individual  is  incapacitated  for  marriage  by 
reason  of  his  own  personal  risks  from  the  disease.  Observation  shows  most 
conclusively  that  after  a  certain  period  of  probation,  during  which  he  has  been 
subjected  to  active  treatment,  the  syphilitic  man  may  marry  and  not  infect 
his  wife,  and  beget  children  who  remain  free  from  any  sign  of  syphilitic  taint. 
There  is  no  fact  better  established  than  that  the  contagious  and  transmissivo 
power  of  syphilis  may  be  extinguished  by  time  and  treatment. 


SYPHILIS    AND    MARRIAGE.  445 

To  the  next  question  wliicli  frequently  follows  the  first — When  or  how 
soon  can  I  marry  ? — the  response  is  not  so  direct  or  positive.  It  may  be 
laid  down  as  a  cardinal  principle,  which  must  serve  as  the  criterion  of  the 
physician's  advice  in  all  cases,  that  no  syphilitic  should  marry  so  long 
as  he  is  capable  of  infecting  his  wife  or  transmitting  the  dis- 
ease to  his  offspring.  While  the  contagious  stage  of  syphilis  is  not  the 
exact  measure  of  the  duration  of  its  hereditary  influence,  there  is  a  certain 
concordance  between  the  two  periods.  A  syphilitic  husband  who  has  no  con- 
tagious lesions  on  his  person  may  be  dangerous  to  his  wife  through  conceptional 
syphilis. 

Certain  facts  of  our  knowledge  bearing  upon  the  duration  of  this  period 
may  be  summarized  as  a  basis  for  the  physician's  judgment:  (1)  The  dura- 
tion of  the  period  of  the  contagious  and  transmissive  power  of  syphilis  does 
not  admit  of  mathematical  expression.  It  varies  in  different  cases.  (2)  The 
type  of  the  disease,  the  constitutional  peculiarities  of  the  patient,  the  presence 
or  absence  of  certain  conditions  which  are  recognized  as  factors  of  gravity  in 
syphilis,  and  especially  the  treatment  employed,  all  exert  a  modifying  influ- 
ence. (3)  All  these  elements  should  be  taken  into  consideration  in  deciding 
upon  the  admissibility  of  a  syphilitic  man  to  marriage ;  each  case  should  be 
studied  upon  its  individual  merits.  (4)  The  advanced  age  of  the  diathesis,  a 
prolonged  immunity  from  specific  manifestations,  and  suflicient  specific  treat- 
ment are  the  surest  guarantees  of  safety. 

It  may  be  positively  affirmed  that  the  chronological  completion  of  the  sec- 
ondary stage  does  not  mark  the  limit  of  its  contagious  activity,  as  formerly 
supposed.  There  are  well-authenticated  observations  which  prove  in  the  most 
positive  manner  that  the  late  lesions  of  syphilis,  occurring  five,  six,  or  ten 
years  later,  may  exceptionally  be  sources  of  contagion.  Fournier  has  recently 
reported  a  case  of  contagion  of  the  wife  occurring  in  the  seventeenth  year 
from  a  mucous  patch  in  the  mouth  of  the  husband.  The  advice  of  certain 
authorities,  notably  Hutchinson,  that  "  if  treatment  has  been  continued  from 
two  to  two  and  a  half  years  from  the  date  of  the  chancre  a  man  may  safely 
marry,"  is  medically  a  mistake,  and  socially  a  danger. 

Unfortunately,  in  the  present  state  of  our  knowledge,  there  is  no  scien- 
tifically accurate  means  of  determining  the  precise  date  which  marks  the  defi- 
nite disappearance  of  the  virulent  principle.  If  the  spirocheta  pallida 
be  proven  to  be  the  causal  agent  of  syphilis,  it  is  possible  that  improved  methods 
of  technic  will  enable  us  to  positively  determine  the  presence  or  absence  of 
these  organisms  in  the  body. 

In  the  absence  of  any  trustworthy  test,  reliance  must  be  placed  upon  the 
facts  of  experience  and  observation.  A  careful  interpretation  of  these  facts 
shows  that  in  the  immense  majority  of  cases  the  contagious  activity  of  syphilis 
and  its  hereditary  transmissibility  are  not  manifest  after  the  fourth  year.  It 
may  therefore  be  concluded  that  when  the  syphilitic  diathesis  has  been  sub- 
jected to  the  double  depurative  action  of  time  and  treatment  during  a  period 


446  SYPHILIS, 

of  four  years,  and  there  has  been  an  exemption  from  all  manifestations  dur- 
ing the  last  twelve  or  eighteen  months,  it  is  scientifically  safe  for  the  syj^hilitic 
to  marry.  This,  however,  is  not  a  formula  based  upon  mathematical  certainty, 
but  rather  upon  a  calculation  of  probabilities. 

In  cases  where  active  manifestations  of  the  disease  still  continue  to  recur 
after  this  period,  especially  when  they  consist  of  lesions  of  the  mucous  mem- 
branes, marriage  cannot  be  sanctioned  with  safety.  Observation  shows  that 
recurrent  mucous  patches  of  the  mouth  are  the  almost  exclusive  source  of  late 
contaminations  in  marriage. 

Even  after  the  dangers  of  syphilis,  from  the  standpoint  of  its  contagious- 
ness and  transmissibility  by  inheritance,  have  been  silenced  by  time  and  treat- 
ment, a  syphilitic  man  may  be  incapacitated  for  marriage  by  reason  of  his 
personal  risks  from  the  disease.  Unfortunately,  syphilis  often  yields  a  late 
harvest  of  tabes,  general  paralysis,  and  other  lesions  of  the  general  nervous 
system — affections  for  the  most  part  disabling  and  incurable — ^which  may  ruin 
the  patient's  health  and  entirely  incapacitate  him  for  the  responsible  position 
of  the  head  and  support  of  a  family.  The  existence  of  such  conditions  con- 
stitutes an  express  permanent  contraindication  to  marriage. 

Of  all  menaces  to  the  health  and  life  of  the  individual,  lesions  of  the  nerve 
centres  are  most  common  and  most  to  be  feared,  and  it  is  within  the  sphere 
of  the  nervous  system  that  we  must  look  for  indications  which  point  to  a 
menacing  character  of  the  diathesis.  In  persons  of  neuropathic  constitution, 
especially,  the  determination  of  syphilis  toward  the  nerve  centres,  the  eyes, 
and  the  organs  of  special  sense  always  carries  a  grave  prognostic  significance, 
and  in  such  cases  the  period  of  probation  should  be  lengthened  until  there  has 
been  a  prolonged  exemption  from  all  evidences  of  implication  of  the  nervous 
system. 

The  consideration  of  this  subject  would  be  incomplete  without  reference  to 
the  result  of  the  physician's  advice  in  counselling  the  postponement  of  mar- 
riage of  a  syphilitic  until  time  and  treatment  render  such  a  step  safe. 

In  the  majority  of  cases  the  individual  who  consults  the  physician  in 
rea-ard  to  his  fitness  for  marriage,  does  so  with  the  honest  intention  of  accept- 
ing  and  abiding  by  his  counsel.  However  prolonged  the  probationary  period, 
he  conforms  to  the  conditions  imposed.  Unfortunately,  there  are  many  cases 
where  for  reasons  personal  to  himself — it  may  be  financial  or  other  con- 
siderations— the  patient,  although  fully  instructed  as  to  the  danger  to  his 
prospective  wife,  and  the  practical  certainty  of  infecting  her,  nevertheless 
refuses  to  postpone  his  marriage.  He  prefers  to  take  the  chances — or  rather 
subject  his  wife  to  the  chances — of  infection.  Does  the  physician  ful- 
fill his  entire  duty  in  simply  refusing  to  sanction  the  marriage  ? 

In  this  connection  it  may  be  said  that  the  view  is  held  by  certain  writers 
that  the  sanction  of  marriage  does  not  properly  come  within  the  physician's 
province.  In  the  most  recent  English  text-book  on  Syphilology,  the  author 
gives  expression  to  his  view  as  follows :  "  Is  it  any  business  of  the  medical 


BYPHILIS    AND    MARRIAGE.  447 

man  to  give  his  sanction  to  marriage  at  all?  Marriage  is  a  civil  contract, 
concerned  chiefly  with  matters  other  than  medical.  The  duty  of  the  medical 
man  ends  with  pointing  out  to  his  patient  the  possible  eventualities  in  case  of 
marriage."  In  other  words,  the  poisoning  of  an  innocent  woman  with  syphilis 
is  a  matter  between  husband  and  wife  with  which  the  physician  has  nothing 
to  do.  This  view  seems  subversive  of  the  high  ideals  of  preventive  medicine. 
It  is  the  recog-nized  duty  of  a  physician  in  the  presence  of  any  contagious 
disease  to  protect  others  from  the  risks  of  infection.  In  the  case  of  diph- 
theria, smallpox,  or  any  infectious  disease,  the  physician  may  discharge 
this  duty  by  notifying  the  health  authorities,  who  take  proper  precautions 
to  protect  others  from  the  spread  of  the  disease.  In  the  case  of  syphilis, 
where  there  is  a  question  of  its  introduction  into  marriage,  the  physician's 
protective  duty  embraces  not  only  the  prospective  wife,  but  the  children  she 
may  bring  into  the  world,  and  through  them  the  interests  of  society.  Unfor- 
tunately, syphilis  is  without  the  pale  of  prevention  or  even  recognition  by  the 
official  authorities,  and  the  physician  stands  as  the  only  protector  of  the  inter- 
ests of  the  future  family.  The  question  is  whether  his  socio-sanitary  duty  to 
preserve  others  from  infection  falls  below  his  duty  to  protect  his  patient  in 
infecting  them.  The  answer  to  this  question  trenches  upon  the  domain  of 
professional  ethics.  In  the  solution  of  this  problem,  where  the  physician  is 
confronted  with  a  divided  duty,  common  sense,  as  well  as  humanity  and  con- 
science, should  be  invoked. 

The  medical  secret  in  relation  to  professional  conduct  is  too  complicated 
and  delicate  to  be  properly  considered  within  the  necessarily  restricted  limits  of 
this  article.  In  Prince  Morrow's  work  ("  Social  Diseases  and  Marriage  ")  the 
question  is  discussed  in  all  its  bearings  and  with  especial  reference  to  the  case 
of  a  syphilitic  man,  who,  despite  the  warning  of  his  physician,  proposes 
to  carry  out  his  intention  to  marry,  with  the  practical  certainty  of  infect- 
ing his  wife.  One  quotation  may  be  permitted,  which  applies  to  this  class 
of  cases: 

"  While  the  obligation  of  the  medical  secret  is  in  the  general  interest  of 
the  social  order  and  should  be  maintained  as  a  fixed  principle  of  professional 
conduct,  it  may  be  admitted  that  a  situation  of  a  peculiarly  aggravating  char- 
acter may  present  itself  where  the  patient  shows  himself  an  exceptional  sort 
of  brute  by  the  obstinacy  with  which  he  adheres  to  his  criminal  purpose  after 
he  is  assured  that  he  will  almost  certainly  infect  his  wife — in  such  a  case  the 
physician,  knowing  all  the  circumstances  and  fully  apprecia:£ing  the  tragic 
significance  of  such  a  step,  must  be  guided  by  his  own  lights  and  conscience. 
If  he  should  consider  the  criminal  intent  of  this  man  as  entirely  without  the 
pale  of  professional  protection  and  refuse  to  stifle  his  own  feelings  as  a  man 
of  heart  and  conscience,  who  shall  condemn  him  ?  Such  a  physician  is  far 
more  likely  to  prove  loyal  to  the  highest  ideals  of  ethical  duty  in  his  relations 
with  his  patients  in  general,  than  the  one  who  views  these  social  catastrophes 
with  a  cold-blooded  indifference,  disclaiming  all  personal  responsibility,   and 


448  SYPHILIS. 

considers  that  in  guarding  the  dissolute  secret  of  his  patient  he  is  doing  his 
whole  professional  duty." 

After  Marriage. — While  it  is  the  duty  of  the  physician  co  employ  any 
justifiable  means  to  j^revent  the  premature  marriage  of  a  syphilitic  patient, 
yet  it  most  often  happens  that  he  is  not  consulted  until  after  the  disease  has 
been  introduced  into  the  family. 

The  husband  may  have  contracted  syphilis  at  a  more  or  less  remote  period 
before  marriage,  or  he  may  have  contracted  the  disease  yost  nuptias. 

The  situations  created  by  the  introduction  of  syphilis  into  marriage  are 
varied  and  complicated,  and  render  the  physician's  task  most  difficult  and 
delicate.  The  husband  may  be  syphilitic  and  the  wife  uncontaminated,  the 
wife  may  be  contaminated  and  also  pregTiant. 

When  a  married  man  has  syphilis,  the  first  indication  is  to  prevent  con- 
tamination of  his  wife,  the  second  is  to  guard  against  pregTiancy.  He  should 
be  treated  actively  and  energetically,  with  a  view  of  supjDressing  as  promptly 
as  possible  all  sources  of  contagion.  The  interdiction  of  pregnancy  should  be 
absolute,  until  time  and  treatment  have  exerted  an  attenuating  and  corrective 
influence  upon  the  diathesis. 

If  the  wife  has  become  infected  and  pregnancy  has  taken  place,  she  should 
be  most  energetically  treated  during  the  greater  part  of  the  period  of  her 
pregTiancy.  Specific  treatment,  judiciously  employed,  does  not  tend  to  pro- 
duce abortion.  When  the  pregnancy  results  in  a  child  living,  but  syphilitic, 
it  should  always  be  nursed  by  the  mother,  even  though  she  may  have  appar- 
ently escaped  the  contagion  in  carrying  it.  It  is  a  law  of  syphilis,  first  for- 
mulated by  Colles,  that  a  child,  syphilitic  from  birth,  never  communicates  the 
disease  to  its  nursing  mother. 

The  saddest  feature  of  conjugal  infection  is  that  the  wife  rarely  receives 
the  benefit  of  prompt  and  efficient  treatment.  In  practice  it  will  be  found 
difficult  to  treat  a  woman  during  the  prolonged  period  necessary  to  cure  the 
disease  and  conceal  from  her  the  nature  of  her  trouble.  If  the  husband  can 
be  persuaded  to  avow  the  nature  of  his  disease,  the  situation  is  simplified  and 
there  may  be  an  intelligent  cooperation  on  the  part  of  both  with  the  physician 
in  avoiding  the  deplorable  results  which  come  from  transmission  of  the  dis- 
ease to  the  offspring.  Incredible  as  it  may  appear,  many  husbands  employ 
every  possible  means  to  prevent  their  wives  from  consulting  a  physician  from 
the  fear  of  the  exposure  of  their  own  infidelity,  which  must  come  from  the 
wife's  knowledge  of  the  nature  of  her  disease. 

It  is  not  to  be  assumed  that  all  husbands  who  infect  their  wives  with  syphilis 
are  of  this  class.  Many  of  them  are  overwhelmed  with  regTet  and  remorse,  and 
are  anxious  that  the  wife  should  receive  the  most  thorough  treatment  pos- 
sible, render  these  circumstances,  where  a  syphilitic  patient  calls  in  the  physi- 
cian to  attend  his  wife,  the  important  question  conies  up  whether  the  wife 
should  be  informed  by  her  physician  of  the  nature  of  her  dis- 
ease?     The  fi^ed  rule  of  professional  conduct  in  these  cases,   from  which 


PROPHYLAXIS    THEOUGII    EDUCATION.  449 

there  should  be  no  deviation,  is  that  no  information,  nor  hint  even,  of  the 
nature  of  the  disease,  should  come  from  the  physician.  It  matters  not  what 
may  be  the  feelings  of  indignation  or  disgust  he  may  entertain  for  the  man, 
he  must  zealously  guard  the  secret  of  the  patient.  The  harm  has  been  done 
and  cannot  be  undone.     The  main  indication  is  to  limit  its  ill  effects. 

PROPHYLAXIS    THROUGH    EDUCATION. 

It  is  a  lamentable  fact  that  the  vast  mass  of  disease  and  misery  engendered 
by  the  introduction  of  syphilis  into  marriage,  through  the  infection  of  the  wife, 
with  all  its  train  of  hereditary  horrors,  has  its  origin  in  the  voluntary  act  of 
the  husband  and  father.  It  would  appear  almost  incredible  that  a  man  would 
voluntarily  expose  the  woman  he  has  vowed  to  cherish  and  protect  to  the  risks 
of  an  infection  which  not  only  endangers  her  health,  but  poisons  the  very 
sources  of  the  life  of  his  children.  And  yet  observation  shows  that  syphilitic 
infections  in  married  life  are  by  no  means  rare ;  on  the  contrary,  they  are  fre- 
quent, much  more  frequent  than  is  commonly  supposed.  They  occur  in  every 
class  and  rank  of  society,  not  only  among  the  poor  and  ignorant,  but  among  the 
intelligent  and  well  to  do. 

Statistics  embracing  all  classes  of  women  show  that  of  women  infected  with 
syphilis,  twenty  per  cent,  or  one  in  every  five,  is  contaminated  by  her  husband. 
Excluding  the  abandoned  or  vicious  class,  practically  all  women  who  acquire 
syphilis  receive  the  infection  from  their  husbands. 

The  only  extenuating  feature  of  these  social  crimes  is  that  while  infections 
in  marriage  are  voluntary,  they  are  for  the  most  part  ignorant  infections.  The 
opinion  of  those  who  have  had  large  experience  in  dealing  with  marital  syphilis 
is  concurrent  upon  this  point:  the  basic  cause  is  ignorance.  The  man 
who  carries  disease  and  death  into  his  family  most  often  does  so  because  he 
does  not  know  its  terrible  consequences  to  his  wife  and  children;  he  does  not 
know  its  modes  of  contagion,  nor  the  duration  of  its  transmissive  capacity.  Few 
men,  even  among  what  are  termed  the  educated  classes,  have  any  correct  knowl- 
edge of  the  most  common  sources  of  syphilitic  contagion.  They  do  not  know 
that  in  the  large  proportion  of  cases  contagion  is  affected  through  the  medium 
of  mucous  patches. 

In  the  popular  conception  genital  sores  are  the  only  source  of  contagion 
and  when  the  chancre  heals  there  is  no  danger  of  infection.  This  belief  is  not 
surprising  in  view  of  the  fact  that  fifty  years  ago  Ricord's  doctrine,  "  the  con- 
tagion of  syphilis  begins  and  ends  with  the  chancre,"  was  generally  accepted 
by  the  medical  profession. 

In  this  connection  it  may  be  said  that  almost  all  popular  errors  about 
syphilis  are  but  the  discarded  opinions  of  the  medical  profession,  such  for  ex- 
ample as  "  syphilis  is  readily  cured  and  there's  an  end  of  it."  "  A  few  months' 
treatment  is  sufficient  for  a  cure."     "  After  two  years,  or  at  the  most  two  and 

a  half  years,  it  io  perfectly  safe  for  a  syphilitic  man  to  marry,"  etc. 
30 


450  STPHTLIS. 

The  recognition  of  the  chief  cause  of  marital  syphilis  suggests  the  logical 
remedy — Education;  that  is  to  say,  a  general  enlightenment  of  the  public 
respecting  the  dangers  of  syphilis  to  the  individual  and  to  society,  as  well  as  its 
modes  of  contagion,  direct  and  indirect.  It  may  be  said  that  individual  en- 
lightenment may  now  be  had  by  the  syphilitic  patient  consulting  his  physician. 
While  the  sanitary  office  of  the  physician  in  safeguarding  marriage  from 
syphilis  is  of  the  highest  importance,  yet  it  must  be  admitted  that  its  preventive 
value  is  comparatively  restricted,  as,  unfortunate^,  considerations  of  health 
rarely  enter  into  men's  matrimonial  schemes.  Only  a  small  percentage  of 
syphilitic  men  consult  a  physician  as  to  their  fitness  for  marriage  and  parentage. 
Among  the  well-to-do  classes  the  advice  of  the  physician  is  sometimes  sought 
as  to  the  propriety  or  safety  of  marriage,  but  among  the  poorer  classes  the 
physician  is  rarely  consulted.  Then  again,  the  physician  is  not  armed  with 
authority  to  enforce  the  conditions  his  judgment  may  impose;  his  only  weapons 
are  enlightenment  and  persuasion.  While  it  may  be  comparatively  easy  to 
persuade  a  syphilitic  man  whose  marriage  is  a  dream  of  the  future  to  relin- 
quish all  idea  of  its  fulfillment  until  he  is  no  longer  dangerous  to  his  pros- 
pective wife  and  children,  yet  in  practice  the  situation  presented  is  often  quite 
different.  The  physician  is  not  consulted  until  after  an  engagement  is  entered 
into,  possibly  the  date  fixed  and  all  arrangements  for  the  marriage  completed. 

A  by  no  means  inconsiderable  experience  has  convinced  me  that  the  inter- 
vention of  the  physician  in  this  class  of  cases  is  practically  hopeless.  The 
patient,  though  fully  enlightened  as  to  the  possible  and  even  probable  dangers 
of  a  premature  marriage,  can  find  no  easy  way  of  retreat.  A  postponement  of 
the  marriage  during  the  necessary  period  of  probation  and  treatment  is  often 
equivalent  to  a  rupture  of  the  engagement.  Often  he  can  give  no  explanation 
without  the  humiliating  alternative  of  avowing  the  true  cause.  In  most  cases 
he  marries  at  the  time  appointed,  and  his  wife  and  children  suffer  the  conse- 
quences of  his  criminal  folly. 

It  is  evident  that  enlightenment,  to  be  efficient  as  a  prophylactic,  must  be 
timely;  that  is  to  say,  it  must  be  given  before  the  nearness  of  marriage  enters 
as  a  complicating  factor  in  the  situation. 

All  these  facts  emphasize  the  especial  importance  of  educating  the  rising 
generation  of  young  men,  those  who  are  destined  as  future  husbands  and 
fathers  to  continue  the  race.  Practically  all  young  men  include  marriage  at 
a  more  or  less  remote  future  in  their  scheme  of  life.  Every  young  man  should 
know  that  the  contraction  of  syphilis  may  not  only  seriously  compromise  his 
ovm  health,  but  lead  to  a  forfeiture  of  all  those  hopes  and  aspirations  which 
find  their  fruition  in  a  safe,  honorable,  and  fruitful  marriage.  A  knowledge 
of  these  facts  should  be  so  universal  that  no  man  who  aspires  to  marriage, 
whatever  his  degree  of  intelligence  or  station  in  life,  should  be  ignorant  of  the 
danger  and  criminality  of  carrying  syphilitic  infection  into  his  family. 

It  may  be  observed  in  conclusion  that  this  education  should  begin  in  the 
ranks  of  the  medical  profession.     Many  physicians  have  not  kept  pace  with  the 


PROPIIYTwAXIS    THUOUGII    EDUCATION.  451 

advances  made  in  onr  knowledge  of  syphilis  which  especially  emphasizes  its 
social  dangers  and  tlie  importance  of  prophylaxis.  In  our  college  curricula 
this  jihase  of  preventive  medicine  is  rarely  touched  upon,  and  in  our  text  books 
on  syphilis  its  important  relations  with  marriage  receive  brief  and  entirely  in- 
adequate consideration. 

In  the  writer's  experience  quite  a  number  of  syphilitic  men  who  have  mar- 
ried prematurely  and  infected  their  wives  have  declared  that  their  marriage 
was  sanctioned  by  a  physician.  Without  lending  a  too  credulous  ear  to  state- 
ments designed  to  shift  responsibility  to  the  shoulders,  of  another,  there  is 
reason  to  believe  that  many  physicians  are  too  lax  and  indulgent  to  the  wishes 
and  inclinations  of  their  patients.  They  are  disposed  to  view  the  m^atter  from 
the  standpoint  of  the  interested  party  and  impose  only  the  minimum  of  delay. 
Many  physicians  still  hold  the  dangerous  view  that  a  syphilitic  man  may  safely 
marry  after  two  and  a  half  years,  irrespective  of  the  character  of  the  diathesis 
or  the  treatment  employed. 

The  practical  question  remains,  how  and  through  what  agencies  can  this 
prophylactic  education  be  imparted  to  the  public  ?  A  detailed  consideration  of 
"  ways  and  means  "  cannot  be  entered  into  here.  Reference  may  be  made  to 
the  campaign  of  education  recently  inaugurated  in  this  country  by  a  Society 
organized  for  this  purpose.  The  educational  policy  of  this  Society  embraces 
in  its  objects  two  essential  features,  "  Publicity  of  evils  which  have  always 
been  covered  up  and  concealed,"  and  "  Sex  instruction." 

Education  of  the  rising  generation  in  a  knowledge  of  the  origin  of  life,  the 
physiology  and  hygiene  of  sex,  and  the  dangers  both  physical  and  moral,  which 
come  from  the  irregular  exercise  of  the  sex  function,  will,  it  is  believed,  tend 
to  promote  clean  living  and  thus  secure  the  ideal  prophylaxis  which  is  to  pre- 
vent the  contraction  of  disease  which  unfits  a  man  for  marriage. 

It  is  also  believed  that  exposure  of  the  dangers  to  the  family  and  society 
which  come  from  the  introduction  of  syphilis  into  marriage  will  create  a 
healthy,  humane  public  sentiment  which  will  no  longer  tolerate  the  crowning 
evil  of  our  social  life — the  infection  of  virtuous  wives  and  innocent  children. 


CHAPTER    XVIII. 

ABORTION. 

Definition,  p.  452.  Frequency,  p.  452.  Etiologj' :  Causes  due  to  o^'^lm,  p.  454 ;  causes  due  to  mother, 
p.  455.  Mechanism,  p.  457.  Symptoms  and  diagnosis,  p.  458.  Complications,  p.  460.  Treat- 
ment, p.  460.     Septic  abortion,  p.  470.     Criminal  abortion,  p.  473.     Artificial  abortion,  p.  473. 

DEFINITION. 

The  expulsion  of  tlie  oviim  from  the  uterus  before  tlie  sixteenth  week  of 
pregnancy  is  called  by  American  obstetricians,  abortion;  from  that  time  to 
the  twenty-eighth  it  is  commonly  known  as  a  miscarriage  {partus  immaturus 
of  the  Germans)  ;  and  from  the  twenty-eighth  week  to  the  fortieth,  a  premature 
delivery  {partus  preinaturus) .  A  distinction  between  the  first  and  second  con- 
ditions may  seem  arbitrary  and  artificial,  but  there  is  reason  for  it  in  the 
changes  from  the  chorion  to  the  placenta  and  in  the  difference  in  the  mechanism 
of  expulsion  of  the  uterine  contents.  In  the  consideration  of  abortion  the  fetus 
plays  but  a  small  part,  while  the  secundines  (chorion,  amnion,  and  decidua) 
are  of  the  greatest  importance ;  in  the  case  of  premature  delivery  and  delivery 
at  term  the  relative  importance  of  the  two  things  is  reversed. 

HISTORY. 

The  history  of  abortion  reaches  back  to  the  oldest  writers.  Celsus  truly 
attributes  many  cases  of  abortion  to  dysentery,  and  says :  "  when  dysentery  is 
accompanied  with  fever  the  woman  usually  dies."  I  have  often  been  aston- 
ished at  the  close  observation  of  the  ancients  in  regard  to  abortion.  The  fact 
that  it  is  more  dangerous  than  birth  at  full  term  was  fully  recognized  by  them, 
and  Hippocrates  notes  the  frequency  witli  which  some  women  abort  repeat- 
edly at  the  same  month  (Haeser's  "  Geschichte  der  Medicin,"  1875).  Their 
views  on  the  subject  were  so  correct  that  it  is  a  matter  of  surprise  to  find  they 
did  not  regard  the  induction  of  abortion  in  the  early  months  as  a  criminal 
offence.  In  this  respect,  however,  they  are  only  in  accord  with  the  views  pre- 
vailing to-day,  for  it  is  a  common  impression,  even  among  educated  persons, 
that  so  long  as  no  life  can  be  recognized  there  can  be  nothing  wrong  in  causing 
abortion ;  an  idea  which  it  behooves  us  to  do  all  in  our  power  to  eradicate. 

FREQUENCY. 

i^To  accurate  statistics  in  regard  to  the  frequency  with  which  abortion  takes 
place  can  be  obtained ;  the  best  which  can  be  done  is  to  draw  what  conclusions 
452 


STATISTICS    IN    KEGAKD    TO    FKEQUENCY,  453 

are  possible  from  our  case-books,  although  we  at  once  encounter  a  stumbling- 
block  in  the  fact  that  in  these  we  have  to  do  with  sick  women.  An  analysis  of 
eleven  hundred  and  one  cases,  taken  from  the  case-books  of  Dr.  Edward  J.  Ill, 
of  'New  Jersey,  shows  that  out  of  this  number  there  had  been  six  hundred  and 
sixty-three  who  had  had  more  than  one  child ;  three  hundred  and  fifty-four  who 
had  had  only  one  child ;  and  eighty-four  who  had  had  abortions  only.  Among 
the  six  hundred  and  sixty-three  multiparaj  there  had  been  four  hundred  and 
eighty-five  abortions,  which  amounts  to  about  one  abortion  to  every  five  preg- 
nancies. Among  the  primiparse,  that  is,  women  who  had  had  but  one  child,  there 
had  been  one  hundred  and  forty  abortions,  that  is,  about  one  abortion  to  every 
two  and  five-tenths  pregnancies;  while  the  remaining  eighty-four  women,  who 
had  never  carried  a  child  beyond  the  fourth  month,  had  had  one  hundred  and 
three  abortions.  The  large  proportion  of  abortions  in  the  primiparse  may  be 
accounted  for  by  the  fact  that  their  labors  were,  in  many  cases,  severe.  These 
figures  are  not  in  harmony  with  those  of  some  other  observers,  but  it  must  be 
remembered  that  these  women  were  affected  with  some  pelvic  lesion  and  were 
thus  more  subject  to  spontaneous  abortion. 

These  figures  show  how  uncertain  such  statements  must  always  be,  and  that 
in  order  to  get  accurate  statistics  they  must  be  taken,  after  the  menopause,  from 
a  large  number  of  women.  All  that  can  be  said  on  the  subject  is  that  a  con- 
sultation of  the  works  of  most  authorities  shows  them  to  agree  that  the  fre- 
quency of  abortion  to  birth  at  full  term  is  from  one  in  five  or  six  to  one  in  ten, 
and  that  the  third  month  is  the  time  when  it  most  frequently  takes  place.  It 
seems  also  to  be  generally  agreed  that  as  women  grow  older  they  are  more  sub- 
ject to  abortion,  which  is  what  would  naturally  be  expected,  as  the  pelvic  organs 
become  more  subject  to  pathological  changes  as  life  advances.  Stumpff  gives 
the  following  figures  on  this  point  (Munch,  med.  Wochenschr.,  1892,  I^Tos.  43 
and  44)  : 

Per  cent 

Before  the  age  of  21  years 23.6 

From    21-25  years 22.5 

"       26-30      "       31.0 

"       31-35      "      27.1 

"       36-40      "       27.5 

Above  40  "       36.6 

It  is  a  matter  of  common  opinion  that  abortions  are  most  apt  to  occur  at 
times  when  the  patient  would  naturally  expect  a  return  of  her  menses.  Con- 
tractions of  the  uterus,  induced  by  the  customary  ovarian  stimulation,  may  be 
the  cause  of  abortions  at  these  times;  or  the  death  of  the  fetus  may  excite 
renewed  activity  of  the  ovary.  I  have  sometimes  observed  that  an  exception- 
ally large  number  of  abortions  occur  midway  between  two  expected  periods,  for 
example,  at  six  or  at  ten  weeks. 


454 


ABOKTION. 


ETIOLOGY. 


There  are  always  more  cases  of  abortion  among  multipara^  than  primiparse, 
but  this  is  simply  because  multipara?  are  in  the  majority  and  also  because  they 
are  more  subject  to  uterine  derangements.  The  causes  of  spontaneous  abortion 
must  be  looked  for  in  both  mother  and  child,  but  a  study  of  a  number  of  such 
cases  shows  that  mechanical  and  psychical  influences  are  much  less  frequently 
concerned  in  their  etiology  than  true  pathological  conditions  of  either  the  ovum 
or  the  parental  organism.  The  term  habitual  abortion  is  much  used,  but 
it  does  little  toward  an  understanding  of  either  the  pathology  or  the  causation 
of  the  condition. 

Causes  of  Abortion  Due  to  the  Ovum. — Many  observers  have  noticed  the  oc- 
currence of  various  malformations  and  changes  in  the  normal 
growth  of  the  ovum  as  a  cause  of  abortion.  As  far  back  as  1S39,  Allen 
Thomson  {Edin.  Med.  and  Surg.  Jour.,  1839)  called  attention  to  the  presence 
of  adhesions  between  the  back  of  the  fetus  and  the  membranes.  The  origin  of 
such  malformations  is  not  known.  Some  observers  have  attributed  them  to  the 
spermatozoa,  especially  in  chronic  alcoholism,  but  how  far  this  is  really  in  ac- 
tion as  a  cause  is  difficult  to  say. 

The  primary  death  of  the  fetus  may  be  induced  by  imperfect  vascu- 
larization of  the  amnion.  Hemorrbages  into  the  chorion  caused 
by  trauma  are  said  to  be  the  occasion  of  some  of  the  deformities  of  the 
fetus,  as  well  as  adhesion  of  the  fetus  to  the  amnion.  Hydr am- 
nion in  early  pregnancy  is  more  likely  to  be  the  result  of  the  dead 
fetus  than  the  cause  (L.  Seitz,  v.  Winkel's  "  Handbiich  der  Geburtshiilfe  "). 
Hegar  ("Beitrage,"  1902,  Band  6,  Hft.  2),  in  a  study  of  twenty-four 
abortions,  found  that  in  eleven  there  was  primarily  disease  of  the  fetal  mem- 
brane, the  degeneration  beginning  in  the  chorion.  Bar  (Frommel's  "  Jahres- 
bericht,"  1903)  has  shown  that  a  faulty  insertion  of  the  ovum  into  the 
horn  of  the  uterus  may  give  rise  to  premature  uterine  contractions  and  conse- 
quent expulsion  of  the  product  of  conception.  Again,  a  low  insertion  of 
the  ovum,  leading  to  placenta  pra?via,  is  sometimes  a  factor  in  abortion.' 
Hemorrhage  into  the  chorion,  and  between  the  chorion  and  the 
decidua,  commonly  known  as  "molar  pregnancy,"  is  a  common  cause  of 
death  of  the  fetus ;  in  such  cases  it  rapidly  disappears,  as  if  by  absorption,  leav- 
ing the  amnion  as  a  small  bag  containing  a  little  clear  or  slightly  blood-stained 
fluid.  It  is  most  commonly  in  these  cases  tbat  we  meet  with  tbe  so-called 
^'missed  abortions,"  a  condition  where  the  product  of  conception  remains 
in  utero  for  weeks,  or  even  months,  without  any  evident  symptoms.  Xow 
and  then  a  hydatidaform  degeneration  of  the  chorion  results  in 
abortion,  and  this  condition  was  well  known  to  the  ancients.  The  fetus 
may  also  die  from  infection,  without  any  disease  of  the  mother; 
one  case  lias  been  re])orted  in  wliich  the  fetus  had  smallpox,  while  the 
motlier  renuiined  well  ( S.  Cliasan).     Eare  cases  have  been  described  of  abor- 


CAUSES    OF    ABORTION    DUE    TO    MOTHEE. 


455 


tion  in  twins  in  which  one  ovum  was  expelled  while  the  other  continued  its 
growth. 

Causes  of  Abortion  Due  to  the  Mother. — Various  infections  of  the 
mother  maj  cause  death  of  the  fetus.  According  to  Charpentier  (Centrbl.  f. 
Gyn.j  1898,  vol.  22,  p.  198)  measles  was  the  cause  of  abortion  twenty- 
three  times  in  fifty-one  cases.  Scarlet  fever,  smallpox,  typhoid- 
fever,  pneumonia,  erysipelas,  appendicitis,  and  other  febrile  dis- 
orders are  frequent  causes,  and  the  fact  that  abortions  occur  most  frequently  in 
them  when  the  temperature  is  high,  shows  a  relation  between  its  occurrence  and 
the  severity  of  the  disease.  As  regards  the  chronic  infections,  abortions  have 
been  attributed  to  tuberculosis  in  the  mother  in  a  few  cases  (Birch- 
Hirschfeld). 

Syphilis  has  always  played  a  large  part  as  a  causative  factor  in  abortion, 
but  while  there  is  no  doubt  as  to  its  influence  as  a  cause  of  premature  labor, 
its  share  in  the  etiology  of  abortion  is  more  difficult  to  determine,  because  of 
the  absence  of  definite  syphilitic  lesions  of  the  ovum  or  fetus  before  the  six- 
teenth week.  L.  Seitz  (v.  Winkel's  "  Geburtshlilfe  ")  attributed  five  abortions 
in  one  hundred  and  nine  cases  of  pregnant  syphilitics,  or  four  and  one-four- 
teenth per  cent,  to  the  influence  of  the  syphilitic  poison.  Other  authorities  give 
syphilis  as  the  cause  of  abortion  in  from  four  and  three-tenths  per  cent  to 
twenty-five  per  cent.  Seitz,  after  a  thorough  sifting  of  the  question,  insists 
that  the  more  recent  the  infection  the  more  likely  is  there  to  be  an  early 
termination  of  the  pregnancy.  Syphilis  has  for  a  long  time  had  the  reputation 
of  inducing  recurrent  abortions.  I  might,  however,  state  that  I  have 
never  but  once  been  able  to  control  recurring  abortions  by  means  of  any 
syphilitic  treatment.  In  the  single  case  the  patient,  who  was  known  to  be 
syphilitic,  aborted  six  times,  and  then  after  five  months  anti-syphilitic  treat- 
ment gave  birth  to  a  living  and  healthy  child  {Med.  Bee,  Oct.  6,  1894). 

Circulatory  disturbances,  induced  by  the  various  heart  lesions,  are 
a  fruitful  source  of  abortion,  by  the  production  of  hemorrhages  behind  and  into 
the  decidua. 

The  part  played  by  trauma  in  the  causation  of  abortion  is  difficult  to 
decide  in  any  given  case.  A  most  careful  examination  of  the  uterine  contents, 
placenta,  chorion,  and  fetus  is  imperative  before  an  opinion  can  be  formed.  If 
shortly  after  the  occurrence  of  trauma  an  abortion  occurs  in  which  there  is  an 
old  degeneration  of  the  decidua  with  small-celled  infiltration,  atrophy  of  the 
chorionic  villi  (Oliver,  Brit.  Med.  Jour.,  Feb.  15,  1902),  hemorrhages  under- 
going •  some  organization,  or  maceration  of  the  ovum,  it  may  be  confidently 
stated  that  the  traumatic  influence  is  not  concerned  in  the  abortion  (Hegar, 
"  Der  Abort.,"  1002).  From  a  medico-legal  point  of  view  the  question  of 
trauma  is  of  great  importance. 

Psychic  disturbances  and  excessive  cohabitation,  especially 
when  the  latter  takes  place  at  a  time  Avhen  menstruation  might  otherwise  be 
expected,  are  frequent  causes  of  abortion. 


456  ABORTION. 

Acute  poisoning  by  means  of  alcohol  (Drappier,  Frommel's  "Jahres- 
bericbt,"  1896),  phosphorus,  lead  and  other  poisons  is  a  factor  in  abor- 
tion. It  is  also  important  to  remember  that  certain  drugs,  such  as  aloes, 
senna,  and  other  purgatives  may  induce  abortion  with  sensitive  patients, 
though,  fortunately,  only  when  administered  in  excessive  doses.  Cotton- root, 
a  popular  remedy  in  the  Soutli,  has  the  reputation  of  being  responsible  for 
causing  abortions,  as  well  as  savine,  tansy,  and  oil  of  pennyroyal; 
the  two  last  are  said  to  be  less  efficient  than  the  others.  The  effect  of  cotton- 
root  upon  the  muscular  contractions  of  the  uterus  is  apparent  in  many  cases  of 
uterine  myomata  where  the  main  symptom  is  an  excessive  flow,  when  it  is  given 
for  several  days  before  menstruation  appears,  and  kept  up  while  it  lasts.  Iron 
also  has  been  known  to  cause  uterine  contractions. 

Certain  diseases  of  the  genital  organs  are  a  prolific  cause  of  abor- 
tion, especially  endometritis,  more  commonly  in  the  hyperplastic  and 
hemorrhagic  forms,  l^ot  infrequently  a  chronic  metritis  (really  hyper- 
plasia of  the  inter-muscular  cellular  tissue),  coupled  always  with  an  en- 
dometritis, may  be  looked  for  as  a  causative  factor.  The  same  thing  can  be 
said  of  retroversions  and  retroflexions  of  the  uterus,  with  their  accom- 
panying endometric  changes. 

The  various  forms  of  decidual  inflammation,  gland  hypertrophy, 
general  diffuse  hypertrophy,  and  polypoid  thickening,  are  be- 
lieved to  be  causal  factors  (Hurdon,  "  Gynecology  and  Abdominal  Surgery," 
Kelly  and  Xoble,  vol.  1,  1907).  Inflammatory  changes  in  the  de- 
cidua    are  probably  a  more  frequent  cause  than  is  commonly  suspected. 

Injury  to  the  cervix  has  been  shown  by  T.  A.  Emmet  ("Principles 
and  Practice  of  Gynecology,"  188i)  to  be  a  frequent  cause  of  early  interruption 
of  pregnancy,  though  he  makes  no  distinction  between  miscarriages  and  abor- 
tions. Olshausen  {"  Klin.  Beitrage  f.  Geburtshiilfe  imd  Gynakologie,"  Feb., 
1884)  has  drawn  attention  to  the  same  fact.  A  patient  of  mine  once  had  four- 
teen abortions  in  succession,  and  then,  after  an  operation  for  deep  laceration 
of  the  cervix,  became  the  mother  of  a  living  child.  Amputations  of  the  cervix 
are  not,  in  my  own  opinion,  the  cause  of  abortion  to  any  great  extent. 

Abortions  at  the  fifteenth  or  sixteenth  week  are  often  due  to  retroflexion 
and  retroversion.  Prolapse  of  the  uterus  and  pelvic  adhesions  are 
factors  in  producing  premature  contractions  of  the  uterus.  Abortions  are 
sometimes  due  to  shortened  and  sensitive  utero-sacral  ligaments 
and  indurations  in  the  base  of  the  broad  ligament.  In  these  cases 
several  successive  abortions  have  occurred,  the  patient  going  longer  with  each 
pregnancy ;  the  pregnancies  were  accompanied  by  pain  in  the  affected  side. 
Similar  cases  have  been  reported  by  Kleinwachter  (ZeitscJir.  f.  Geh.  u.  Gyn., 
1903,  vol.  49,  p.  1).  I  have  never  yet  seen  an  abortion  in  a  myomatous 
uterus,  though  it  is  reported  to  be  moderately  frequent. 

Disease  of  the  adnexa  is  reported  to  be  a  cause  of  abortion,  by  lead- 
ing to  pelvic  adhesions,  and  also  a  lack  of  development   of  the  uterus. 


MECHANISM    OF    ABOKTIOIT.  457 

Operative  procedures  during  pregnancy  are  quite  frequently  a 
source  of  trouble,  though  ovarian  tumors,  and  even  pedunculate  and  sessile 
myomata,  have  been  removed  without  interfering  with  its  progress.  I  once 
removed  a  sessile  myoma  weighing  sixteen  pounds  from  a  uterus  five  months 
pregnant  without  injuring  the  product  of  conception;  the  patient  went  to  full 
term.  Even  lacerations  of  the  cervix  have  been  operated  upon  without  unto- 
ward result.  It  is  well  known,  however,  that  operations  on  the  cervix,  the 
vagina,  the  external  genitalia,  and  the  breasts  are  peculiarly  apt  to  excite  the 
uterus  to  contraction;  and  experience  has  shown  that  from  twenty  to  thirty 
per  cent  of  cases  operated  upon  during  pregnancy  abort. 

MECHANISM    OF    ABORTION. 

The  mechanism  of  abortion  is  somewhat  different  from  that  of  miscar- 
riage, the  conditions  treating  mainly  of  secundines  and  the  fetus  playing  a 
less  important  part.  It  is  worthy  of  a  careful  study,  for  a  knowledge  of  it  is 
of  great  assistance  in  the  treatment. 

An  accumulation  of  blood  between  the  decidua  vera  and  the  uterine  wall  some- 
times occurs,  and  when  this  hemorrhage  is  slight,  it  produces  no  contractions 
of  the  uterus  nor  disturbance  of  the  circulation  of  the  fetus,  and  the  pregnancy 
may  possibly  go  on  to  term.  If,  however,  contractions  of  the  uterus  occur,  the 
entire  ovum  is  forced  into  the  cervical  canal,  dilating  it  until  the  two  cavities 
are  converted  into  one.  In  such  cases  the  patient  has  usually  a  slight  flow 
before  the  uterine  contractions  are  felt.  This  is  the  common,  it  might  be  said 
the  normal,  mechanism  of  an  abortion,  as  all  membranes  are  cast  off  with  the 
egg  and  the  uterus  remains  in  the  best  shape  for  a  regeneration  of  its  mucous 
membrane  and  involution  of  its  muscular  apparatus.  If,  however,  the  decidua 
serotina  is  adherent,  the  decidua  vera  is  drawn  back  over  the  ovum  as  it  is 
expelled  from  the  uterus,  and  appears  as  a  long  cord  which  may  be  replaced 
over  the  ovum.  When,  owing  to  violent  uterine  contractions,  the  decidua 
breaks,  the  ovum  with  its  shaggy  chorion  may  be  expelled  into  the  vagina  and 
the  decidua  follows  later,  if  at  all. 

Some  good  authorities  assert  that  the  decidua  may  remain,  either  wholly 
or  in  part,  and  regenerate  to  a  normal  mmcosa.  Others  maintain  that  reten- 
tion is  fraught  with  danger  to  the  patient  and  occasions  endometric  changes. 
Retention  of  the  decidua,  unless  it  becomes  saprophytic,  septic,  or  hemorrhagic, 
rarely  produces  any  trouble  and  it  commonly  regenerates  into  a  normal  mucous 
membrane ;  at  all  events  the  danger  of  retention  of  the  decidua  has  been  much 
overrated. 

It  sometimes  happens  that  the  whole  product  of  conception  is  expelled  from 
the  uterine  cavity  into  the  cavity  of  the  cervix,  dilating  the  latter  sufficiently 
to  accommodate  it,  but  failing  to  dilate  the  os.  In  such  a  case  the  examining 
finger  finds  the  cervix  balloon-like,  with  an  extremely  small  os,  usually  easily 
dilated,  and  cleans  it  out  with  a  sweep.     This  condition  was  formerly  misun- 


458  ABOKTION. 

derstood,  and  led  to  tlie  erroneous  belief  that  the  ovum  might  become  attached 
to  the  cervical  mucous  membrane  (Rokitanskj,  Monatsschr.  f.  Gehurtsh.  u. 
FrauenJcr.,  1861,  vol.  17).  In  certain  other  cases  the  os  is  widely  dilated, 
but  the  whole  product  of  conception  remains  in  the  cervical  canal,  because  the 
uterine  contractions  fail  to  expel  it,  and  under  these  circumstances  also  it  can 
be  cleaned  out  with  a  sweep  of  the  finger.  Occasionally,  however,  the  uterine 
contractions  force  everything  into  the  vagina. 

SYMPTOMS    AND    DIAGNOSIS. 

The  symptoms  of  abortion  cannot  be  considered  alone,  but  must  be  treated 
in  connection  with  the  question  of  diagnosis. 

The  diagnosis  of  abortion  rests,  first  of  all,  upon  the  diagnosis  of  uterine 
pregnancy.  The  diagnosis  of  early  pregnancy  is  by  no  means  always  easy,  and 
it  may  require  close  inquiry  into  the  history  as  well  as  careful  manual  examina- 
tion of  the  pelvic  organs  (see  Chap.  YI,  Fig.  59).  The  diagnosis  is  most  difii- 
cult  in  multipar^e,  because  the  physician  may  be  dealing  with  a  pathological 
increase  in  the  size  of  the  uterus.  The  diagnosis  of  pregnancy  being  made, 
the  next  step  is  to  look  for  symptoms  of  abortion,  the  most  prominent  and  con- 
stant of  which  is  a  bloody  discharge  from  the  uterus.  It  is  important  for  the 
physician  to  assure  himself  that  the  flow  actually  comes  from  the  uterine  cavity 
and  not  from  injuries  or  diseases  of  the  vagina.  As  I  have  said,  this  flow 
proceeds  from  a  separation  of  the  decidua  from  the  uterine  wall,  although  in 
rare  instances  it  may  come  from  the  mucous  surface  of  the  decidua,  and  when 
this  is  the  case  abortion  is  not  likely  to  occur.  The  etiology  of  abortion  should 
be  considered  in  the  diagnosis,  and  the  possibility  of  willful  interference  and 
its  character  should  not  be  lost  sight  of,  for  the  prognosis  may  depend  on  this. 

The  most  important  symptoms  of  a  threatened  or  imminent  abortion 
are  a  slight  flow  of  blood  after  a  cessation  of  the  menses  and  a  sense 
of  uneasiness  in  the  pelvis.  These  may  subside  under  proper  care  and 
treatment  and  the  pregnancy  go  on  to  full  term,  a  fact  which  must  be  care- 
fully lx)rne  in  mind  in  every  case  of  abortion.  When,  however,  the  bleeding 
continues  and  the  uterine  contractions  increase  in  severity,  accompanied  with 
pain  in  the  back  and  over  the  pubes,  with  a  frequent  desire  to  urinate,  abortion 
will  certainly  occur.  A  threatened  abortion  is  most  apt  to  be  confounded 
with  the  beginning  rupture  of  a  tubal  pregnancy.  Here  also  we  have  more  or 
less  of  a  flow  of  blood  after  a  cessation  of  menstruation,  besides  acute  pelvic 
pain,  often  simulating  menstrual  pain.  An  error  in  diagnosis  between  these 
two  conditions  is  liable  to  be  followed  by  the  most  serious  consequences,  and  in 
these  days  of  indiscriminate  curetting  especially,  it  must  be  guarded  against. 

A  flow  of  blood  anfl  uterine  contractions  may  be  present  with  an  intra- 
uterine polyp  and  simulate  abortion.  The  history  of  previous  attacks  of 
the  kind,  the  unlikelihood  of  a  cessation  of  menstruation,  and  the  absence  of 
all  symptoms  of  pregnancy  should  point  in  the  proper  direction.     Occasionally 


SYMPTOMS    AND    DIAGNOSIS. 


459 


cases  occur  where  normal  cessation  of  menstruation  has  existed  during  lacta- 
tion, and  the  first  symptom  of  pregnancy  is  a  flow  of  blood  and  an  imminent 
abortion. 

Whenever  a  patient  has  missed  one  or  more  monthly  periods  and  has  a 
show  of  blood,  our  suspicions  must  be  directed  to  the  possibility  of  abortion. 
It  is  always  wise  to  suspect  every  woman  of  being  pregnant  until  the  contrary 
is  established  in  order  to  prevent  calamities.  For  a  patient  may  consult  a 
physician  in  perfect  ignorance  of  her  condition,  or  she  may  intentionally  mis- 
lead him,  in  the  hope  that  a  pelvic  examination  will  induce  an  abortion. 

Occasionally,  a  case  occurs  in  which  it  is  difficult  to  say  whether  the  physi- 
cian is  dealing  with  an  abortion  or  with  its  after  effects.  When  most  of  the 
secundines  have  been  retained,  the  uterus  may  still  seem  large  and  flabby; 
the  great  softness  of  the  supra-vaginal  portion  may  remain  and  suggest  that 
pregnancy  continues.  If,  however,  the  uterus  can  be  felt  to  contract  under  the 
examining  finger,  that  is  to  say  by  bimanual  palpation,  it  is  certain  that  most 
of  the  product  of  conception  has  been  expelled,  and  probably  quite  recently. 
In  a  later  stage  this  sign  no  longer  holds  good,  and  it  may  be  impossible  to 
make  a  diagnosis  without  a  microscopical  examination.  The  size  of  the  uterus 
as  compared  with  the  time  of  probable  pregnancy  should  always  be  considered 
most  carefully. 

When  the  diagnosis  of  imminent  abortion  is  decided  upon,  the  physi- 
cian's first  duty  is  to  determine  whether  the  abortion  is  or  is  not  inevitable. 
It  is  inevitable  when  regular  uterine  contractions  take  place  and 
when  parts  of  the  product  of  conception  have  been  expelled. 
It  is  rare  for  a  pregnancy  to  continue  when  the  ovum  can  be  felt  through  a 
dilated  canal.  Sometimes  a  sudden  cessation  of  the  gastric  symptoms  of  preg- 
nancy indicates  death  of  the  fetus,  and  should  be  considered  in  the  physician's 
opinion.  Finally,  it  must  be  ascertained  whether  the  uterus  has  entirely  ex- 
pelled its  contents,  or  whether  there  are  still  remnants  of  the  product  of  con- 
ception; in  other  words,  whether  there  is  an  incomplete  abortion.  It  is 
wise  to  proceed  slowly  and  carefully  in  the  formation  of  an  opinion  upon  this 
point.  When  there  is  a  gradual  diminution  of  the  flow,  and  a  cessation  of 
pain,  the  abortion  is  probably  complete ;  when  the  flow  continues  with  occa- 
sional exacerbations  it  may  be  assumed  that  pieces  of  the  decidua  are  still  in 
utero.  It  is  well,  however,  to  look  for  further  symptoms.  If  the  abortion 
is  not  complete,  the  body  of  the  uterus  is  probably  soft  and  much  thicker  in 
the  antero-posterior  diameter  than  normal;  and  there  will  be  still  much  com- 
pressibility of  the  supra-vaginal  portions  of  the  uterus  (H.  Sellheim,  MilncJi. 
med.  WocJienschr.,  1902,  ITo.  10).  In  an  abortion  of  the  fourteenth  or  six- 
teenth week  bimanual  compression  of  the  uterus  produces  occasionally  a  sense 
of  grating  or  crackling  that  indicates  a  separation  of  the  placenta.  An  easily 
dilatable  cervix  is  always  suggestive  of  incomplete  abortion. 

The  diagnosis  of  abortion  becomes  most  difficult  when  there  are  tumors  of 
the  uterus  complicating  the  pregnancy,  because  the  diagnosis  of  early  pregnancy 


460 


ABORTION. 


itself  is  peculiarly  hard  in  such  circumstances.     The  history  of  the  case  is  the 


best  guide  under  these  conditions. 

PROGNOSIS. 

The  prognosis  in  abortion  depends  much  upon  its  causation.  Women  rarely 
die  from  spontaneous  abortion,  though  it  is  occasionally  followed  by  ill- 
ness, as  shown  by  chronic  endometric  changes  and  subinvolution,  and,  more 
rarely,  tubal  and  peri-uterine  inflammations.  The  only  fatal  form  of  disease 
associated  with  abortion  is  chorio-epithelioma,  which  is  more  frequent 
than  has  been  supposed. 

The  prognosis  must  be  more  guarded,  hoAvever,  when  abortion  is  the  result 
of  criminal  interference.  Olshausen  (Stock,  I.  D.,  Berlin,  1897)- 
attributes  eighty  per  cent  of  all  septic  abortions  to  criminality.  Various  other 
authorities  place  the  proportion  of  criminal  abortions  at  from  five  to  fifty  per 
cent  of  the  total  number. 

COMPLICATIONS. 

The  complications  of  abortion  may  be  summed  up  as  follows : 

(1)  Hemorrhage: 

(a)  Profuse. 
(6)    Continued. 

(2)  Sepsis. 

(3)  Retention  of  secimdines,  or  incomplete  abortion. 

(4)  Ketrodisplacements. 

(5)  Uterine  tumors. 

(6)  Extra-uterine  pelvic  disease. 

(7)  Diseases  of  other  organs. 

TREATMENT. 

The  treatment  of  abortion  may  be  divided  into  four  classes,  namely: 

(1)  Preventive: 

(a)   Before  another  pregnancy  occurs. 

(&)   Before  symptoms  of  abortion  appear. 

(c)   Before  threatened  or  imminent  abortion  occurs. 

(2)  During  progress  of  abortion. 

(3)  After-treatment. 

(4)  Treatment  of  sequelae. 

(1)  Preventive  Treatment. — In  the  case  of  a  woman  who  has  repeatedly 
failed  to  carry  the  product  of  conception  to  term,  the  treatment  must  often 
begin  before  pregnancy  occurs.  The  symptoms,  both  subjective  and  objective, 
must  be  carefully  analyzed  and  any  defect  suggested  by  them  remedied.  If 
there  is  any   history   of   syphilis,    the   prospective   father   should   be 


PREVENTIVE    TREATMENT.  /^Ql 

treated  as  well  as  the  mother.  Such  treatment  too  often  fails,  because 
of  the  well  known  apathy  and  carelessness  of  the  syphilitic,  and  therefore 
strenuous  exertions  must  be  made  in  regard  to  it.  Some  writers  strongly  advise 
the  iodides  in  syphilitic  cases;  others  prefer  mercury  alone.  It  is  prob- 
ably immaterial  which  course  is  pursued,  provided  whichever  is  adopted  is 
kept  up  persistently.  If  syphilis  can  be  excluded,  the  physician's  duty  as 
regards  the  husband  is  for  the  time  at  an  end ;  it  is  true  that  he  is  often  re- 
sponsible for  the  occurrence  of  repeated  abortions,  even  when  he  is  not  syphilitic, 
but  there  is  no  way  at  present  of  proving  it. 

In  the  treatment  of  the  woman  any  disease  of  the  uterus  should  be 
the  object  of  attention.  If  there  is  a  hyperplastic  endometritis,  a 
thorough  curettage,  followed  by  an  application  of  equal  parts  of  tincture  of 
iodine  and  carbolic  acid,  should  be  tried.  A  laceration  of  the  cer- 
vix must  be  repaired,  and  if  there  is  much  erosion  of  the  cervical  membrane 
or  degeneration,  either  cicatricial  or  cystic,  the  cervix  should  be  amputated.  If 
the;  uterus  is  large  and  soft  the  following  prescription  is  often  of  service : 

^  Ext.  ergot,  fl 15.0,  1  part 

Potass,  bromid 15.0, 

Glycerin 15.0, 

Aq.  dest 00.0,  6  parts 

M.     S.   Teaspoonful  in  water  after  meals. 

This  should  be  given  for  a  month,  unless  contra-indicated  by  the  appearance 
of  a  rash,  or  much  mental  depression,  both  of  which  results  are  rare.  Large 
douches  of  hot  water  taken  daily,  with  the  patient  in  the  dorsal  posture, 
will  assist  in  reducing  the  size  of  the  uterus,  and  glycerin  tampons  in- 
serted every  second  day  are  useful  for  the  same  end.  The  patient  can  introduce 
the  tampons  herself  by  means  of  a  Thomas  cupping  glass,  leaving  it  in  place 
overnight. 

Displacements  of  the  uterus  should  be  corrected  by  some  one  of  the 
means  at  our  command.  Piles  and  fissures  in  ano  must  not  be  over- 
looked as  possible  sources  of  irritation.  Whenever  there  is  a  general  enterop- 
tosis,  a  well-fitting  abdominal  support  should  be  worn;  not  one 
which  pushes  the  abdomen  inward,  but  one  that  lifts  it  up.  General 
hygienic  measures  must  not  be  omitted,  such  as  suitable  clothing,  proper 
exercise  in  the  open  air,  cool  to  cold  water  sponge  baths  on  rising,  and  whole- 
some, easily  digested  food.  In  fact  the  physician  will  always  find  that  it  is 
worth  while  to  inquire  into  the  patient's  habits  of  life,  for  he  may  discover 
something  which  w^ill  greatly  assist  him  in  understanding  the  case. 

When  the  patient  is  already  pregnant,  but  no  symptoms  of  abortion  have 
as  yet  appeared,  the  history  of  former  accidents  should  be  carefully  studied. 
If  it  proves  on  investigation  that  the  earlier  abortions  have  been  in  the  habit 
of  occurring  at  the  time  when  a  menstrual  period  might  otherwise  be  expected, 


462  ABORTION. 

the  ]3atient  mnst  be  kept  quietl}^  in  bed  and  free  from  all  care  at  sucli  times. 
Dr.  Ill  keeps  his  patients  in  bed  for  three  or  four  days  and  gives  the  dates  at 
which  the  rest  should  begin;  he  also  prohibits  all  sexual  intercourse  shortly 
before,  during,  and  immediately  after  such  times,  and  advises  the  avoidance  of 
all  alcoholic  beverages,  coffee,  and  tea.  He  has  found  potassium  bromide 
in  doses  of  ten  grains,  given  in  milk,  three  times  daily  after  meals  extremely 
useful.  The  bromide  has  a  marked  effect  in  reducing  sexual  excitement ;  larger 
doses  are  rarely  required.  The  bowels  should  be  moved  daily  by  Rochelle 
salts  in  the  shape  of  a  Seidlitz  powder,  or,  in  plethoric  women  by 
a  tea  spoonful  of  salts  of  Carlsbad  in  a  tumbler  of  warm  water  before 
breakfast. 

Malpositions  of  the  uterus  should  be  corrected,  but  only  the  gentlest 
and  most  careful  manipulations  should  be  used,  lest  the  very  event  which  is  to 
be  prevented  should  occur.  If  there  is  a  retroversion,  or  a  retroflexion,  or  a 
combination  of  the  two  (which  is  the  usual  condition  of  things),  the  uterus 
should  be  replaced  and  kept  in  place  by  a  pessary  of  small  size.  If  it  is  not 
easily  replaced  by  careful  manipulations,  it  is  best  to  desist  and  order  the 
patient  to  lie  in  the  knee-breast  jDOsture  for  from  five  to  ten  minutes  daily,  on  a 
level  cushion  placed  upon  the  floor,  not  on  a  bed.  If  the  vulva  are  separated 
slightly  at  the  same  time,  the  air  will  rush  into  the  vagina  and  enhance  the 
postural  effect. 

Viburnum  pruni folium  may  be  given  for  Aveeks  or  even  months  at  a 
time  as  a  uterine  sedative,  and  it  has  been  highly  spoken  of  for  that  purpose. 
It  is  best  given  in  the  form  of  the  fluid  extract,  in  twenty  drop  doses  every 
four  hours  during  the  day.  Iodide  of  potash  with  iron  has  been  sug- 
gested for  the  treatment  of  habitual  abortions,  no  matter  what  may  be  their 
cause  (Lomer,  Zeitschr.  f.  Get.  u.  Gyn.,  1901,  vol.  46,  p.  306).  In  nervous 
and  excitable  women  tincture  of  valerian  or  valerianate  of  zinc  is 
serviceable. 

When  abortion  is  threatened  or  imminent,  the  history  of  former 
abortions  must  again  be  carefully  studied,  as  regards  character,  relation  of 
occurrence  to  regular  menstrual  periods,  and  age  of  former  interrupted  concep- 
tions. If  the  former  abortions  have  been  preceded  by  a  slight  flow,  at  or  near 
a  time  when  menstruation  would  be  expected,  the  patient  must  be  put  to  bed 
immediately  on  the  appearance  of  the  first  symptoms  of  a  flow  of  blood  or  of 
pain.  The  case  need  not  be  regarded  as  hopeless,  for  even  large  hemorrhages 
may  not  be  followed  by  abortion,  and  the  patient  may  be  encouraged  accord- 
ingly. She  must  be  kept  absolutely  quiet  with  small  doses  of  opium  (0.02 
grams,  or  one-third  of  a  grain,  every  two  or  three  hours),  preferably  often 
repeated,  not  so  much  for  the  effect  of  the  drug  on  the  uterus  as  for  the  general 
quieting  influence  upon  the  system.  Cannabis  indica  in  the  form  of  the 
tincture,  given  in  ten  drop  doses  every  two  hours,  is  sometimes  most  satisfac- 
tory. Yiburnum  pruni  folium  and  asafoetida  are  highly  recommended, 
and  both  of  them  can  be-  given  indefinitely,  which  is  not  the  case  with  the  other 


TREATMENT  DURING  PROGRESS  OF  ABORTION.  4g3 

drugs  mentioned.  The  bowels  should  be  kept  open  by  means  of  a  mild  laxa- 
tive, jDreferably  a  saline.  All  excitement,  both  mental  and  physical,  should 
be  carefully  avoided,  sexual  intercourse  prohibited,  and  a  very  light  diet 
advised.  The  importance  of  absolute  mental  quietude  cannot  be  overestimated 
nor  too  much  impressed  upon  the  patient's  friends.  It  is  a  good  plan  to  keep 
the  patient  on  her  back  with  the  foot  of  the  bed  elevated  from  ten  to  twelve 
inches,  and  only  a  small  pillow  under  her  head ;  this  posture  reduces  the  influx 
of  blood  into  the  pelvic  organs  and  has  a  marked  tendency  to  empty  the  veins. 
In  many  instances  it  will  tide  the  patient  over  a  critical  period. 

Vaginal  examinations,  whether  instrumental  or  digital, 
should  be  restricted;  the  use  of  light  tamjDonade  of  the  vagina,  advised 
by  some  authorities,  is  of  no  service,  and  often  proves  fatal  to  the  ovum.  A 
light  hot-water  bag  over  the  pubes  sometimes  relieves  the  uterine  contractions. 
The  patient  must  be  kept  in  bed  for  several  days  after  the  flow  and  the  pains 
have  ceased,  and  only  gradual,  careful  exercise  should  be  permitted  when  she 
first  gets  about  again.  The  importance  of  easy  evacuations  of  the  bowels  must 
be  insisted  upon. 

When  the  flow  continues  for  a  long  time,  weakening  the  patient  to  a  marked 
degree,  it  may  be  necessary  to  hasten  the  abortion,  but  so  long  as  there  is  any 
likelihood  of  a  living  fetus,  the  advice  and  concurrence  of  a  second  practitioner 
should  be  asked  before  taking  active  measures. 

Treatment  during  Progress  of  Abortion. — If,  in  spite  of  all  endeavors,  abor- 
tion takes  place,  the  treatment  may  be  either  expectant  or  active.  These 
two  forms  of  therapy  should  not  be  regarded  as  diametrically  opposite,  but 
rather  supplemental,  one  to  another.  The  expectant  plan  of  treatment  is  right 
and  justifiable  up  to  a  certain  point,  just  as  it  is  in  labor  at  term;  but  when 
the  natural  forces  fail,  or  dangerous  hemorrhage  appears,  active  treatment  must 
be  vigorously  enforced. 

Expectant  treatment  may  be  furthered  by  such  drugs  as  ergot  and 
gossypium,  which  must  not,  however,  be  given  in  large  doses  for  fear  of 
causing  tetanic  contractions.  This  is  especially  true  of  ergot,  which  has,  at 
times,  a  tendency  to  contract  the  cervix. 

The  dangers  of  expectant  treatment  lie  in  the  fact  that  the  patient 
may  suffer  great  detriment  to  health  by  reason  of  prolonged  confinement  and 
improper  involution  of  the  uterus,  and  also  it  may  afford  opportunity  for 
septic  infection.  Hellender  has  reported  an  important  and  interesting  investi- 
gation into  seventy-four  prolonged  abortions  in  which  not  one  uterus  remained 
sterile ;  all  contained  bacteria  though  only  twenty  of  the  patients  had  any  fever 
(Deutsch.  Gesellsch.  f.  Gyn.,  1903).  Bacteria  find  their  way  into  the  uterus 
along  with  coagula  of  blood  or  membranous  material  which  hang  from  the 
cervix.  Sepsis  is  also  to  be  feared  when  many  instrumental  or  digital  exami- 
nations are  made,  indeed,  it  is  true  in  abortion,  as  in  labor,  that  the  more 
numerous  the  examinations  the  greater  the  danger  of  sepsis.  The  bad  habit 
which  some  women  have  of  making  digital  examinations  themselves,  is  undoubt- 


464  ABOETIOK. 

edlj  a  source  of  sepsis.  Expectant  treatment  may  even  prove  fatal  in  the  case 
of  abortion  which  is  the  result  of  criminal  interference. 

In  abortion  we  have  to  do  with  a  pathological  process  where  nature  does 
the  work  of  repair  with  greater  tenderness  and  completeness  than  we  can,  and 
therefore  there  should  be  here,  as  in  all  surgical  work,  distinct  indications  for 
active  treatment.  So  long  as  the  patient's  health  does  not  suffer,  the  expectant 
plan  of  treatment  may  safely  be  continued.  An  important  indication  for  active 
interference  is  excessive  hemorrhage,  which  is  most  common  in  the 
twelfth  to  the  sixteenth  weeks,  when  the  vascularization  of  the  parts  is  great. 
Hemorrhages  also  occur,  now  and  then,  in  the  earlier  months,  but  life  is  rarely 
endangered  by  them  at  this  stage.  If  the  hemorrhage  is  slight  and  the  ovum 
has  not  ruptured,  it  is  well  not  to  be  too  hasty  in  active  treatment.  Excessive 
hemorrhage  can  often  be  prevented  by  bringing  about  uterine  contractions  and 
securing  separation  of  the  decidua,  and  the  longer  pregTiancy  has  continued  the 
more  important  is  this  measure — the  hemorrhage  at  the  fourth  month  is  often 
appalling.  A  most  satisfactory  way  of  carrying  out  this  measure  is  the  intro- 
duction of  a  firm  vaginal  tampon  of  iodoform  gauze,  which  is  left  in  situ  for 
from  twenty-four  to  forty-eight  hours.  In  cases  where  the  cervix  closes  upon 
the  secundines  after  expelling  the  fetus,  a  vaginal  tampon  will  often  cause  a 
reopening  of  the  canal.  Iodoform  gauze  is  most  satisfactory  because  it  is  less 
apt  to  take  on  a  foul  odor  in  course  of  time  than  plain  sterile  gauze.  The 
gauze  should  be  a  strip  five  yards  long  and  three  inches  wide  and  the  tampon 
should  be  applied  with  the  patient  in  the  Sims,  or  better  still,  in  the  dorsal 
posture,  when  most  attention  can  be  paid  to  cleanliness.  A  Sims  speculum 
should  be  used  to  retract  the  perineum  and  the  gauze  is  pushed  up  along  the 
hollow  of  the  blade  with  a  dressing  forceps,  taking  small  lengths  and  pushing 
them  well  into  place,  much  after  the  maimer  of  a  dentist  when  filling  a  tooth. 
Thus  Douglas'  cul-de-sac  is  first  filled,  then  the  right  fornix,  then  the  left,  then 
the  vault  anterior  to  the  cervix,  and  lastly  the  vagina. 

It  is  hardly  necessary  to  say  that  a  vaginal  tampon  has  lost  its  usefulness 
when  the  product  of  conception  has  been  forced  into  the  cervical  canal.  Its 
removal  is  best  accomplished  by  means  of  a  small  right-angled  tenaculum, 
slipped  along  the  posterior  wall  of  the  vagina.  The  gauze  is  caught  and  with- 
drawal Avith  but  slight  inconvenience  to  the  patient.  It  often  happens  that 
the  whole  product  of  conception  is  found  in  the  vagina  when  the  tampon  is 
removed.  Astringent  tampons  should  never  be  used,  because  of  their  irritat- 
ing effect  upon  the  vaginal  mucous  membrane  and  the  danger  of  furnishing 
a  nidus  for  septic  infection.  Styptics,  whether  vaginal  or  intra-uterine,  are, 
in  my  own  opinion,  of  no  use  at  all. 

Intra-uterine  Tampons. — Uterine  tampons  are  occasionally  service* 
able  in  the  control  of  hemorrhages,  by  their  power  of  inducing  uterine  contrac- 
tions. They  also  assist  in  the  separation  and  possibly  in  the  expulsion  of  the 
uterine  contents,  besides  checking  hemorrhage,  dilating  the  cervical  canal,  and 
preparing  the   uterus   for   further   manipulation,    if  necessary.      A    uterine 


TREATMENT  DURING  PROGRESS  OF  ABORTION.  4g5 

tampon  should  never  be  used,   however,  when  a  vaginal  one  will 
suffice,    for  the  danger  of  sepsis  as  well  as  of  injury  to  the  uterine  wall  is 
much  gTeater;  moreover,  there  is  no  certainty  that  the  hemorrhage  is  perma- 
nently relieved,  for  the  bleeding  decidua  may  remain  in  utero. 
The  indications  for  the  use  of  uterine  tampons  are: 

(1)  Failure  of  uterine  contractions. 

(2)  Failure  of  vaginal  tampons  to  give  desired  result. 

(3)  Expulsion  of  the  fetus  during  the  latter  weeks  in  which  abortion  may 
occur  (twelfth  to  sixteenth)  followed  by  contraction  of  the  cervix. 

(4)  Intimate  adhesion  between  the  decidua  and  the  secundines  and  the  uter- 
ine wall,  causing  violent  hemorrhage  on  the  attempt  to  remove  the  secundines. 

(5)  Persistent  hemorrhage  after  removal  of  secundines. 

In  the  last  case  the  intra-uterine  tampon  will  assist  in  the  removal  of  par- 
ticles of  decidua  where  the  finger  or  curette  have  failed,  on  account  of  softness 
or  sponginess  of  the  uterus. 

Method  of  Introducing  Uterine  Tampons. — The  best  material  for 
a  uterine  tampon  is  ten  per  cent  sterile  iodoform  gauze,  in  strips  two  inches 
wide  and  five  yards  long.  These  should  be  kept  in  readiness  in  screw-capped 
bottles,  covered  with  a  piece  of  sterile  cotton  or  plain  sterile  gauze ;  the  outside 
gauze  can  be  used  to  wipe  the  vagina  dry.  The  patient  must  be  prepared  as 
for  a  major  operation,  on  account  of  the  risk  of  septic  infection.  The  vulva 
should  be  shaved,  and  scrubbed  with  soap  and  water;  the  vagina  flushed  with 
a  solution  of  bichloride  of  mercury  (1:  5000).  The  patient  is  then  placed  on 
a  table,  in  the  dorsal  posture,  with  a  Kelly  pad,  real  or  extemporized,  under 
the  buttocks  and  her  feet  held  up  by  stirrups.  Sterilized  towels  should  be 
laid  over  all  adjacent  parts,  the  vulva  alone  being  exposed.  When  sterilized 
towels  are  not  in  readiness,  they  may  be  prepared  by  placing  the  towels  in  a 
basin  with  a  definite  amount  of  bichloride  of  mercury,  after  which  boiling 
water  is  poured  over  them  in  amount  sufficient  to  make  the  solution  1 :  1000. 
The  cervix  is  exposed  to  view  by  means  of  a  single-bladed  Sims  speculum  (see 
Fig.  108),  inserted  in  the  vagina,  and  then  drawn  towards  the  neck  of  the  blad- 
der by  an  American  bullet  forceps,  so  as  to  straighten  the  cervical  canal.  While 
these  preparations  are  being  made,  the  parts  are  sprayed  with  a  solution  of 
bichloride  (1 :  5000),  and  when  all  is  in  readiness  this  is  shut  off.  The  vagina 
is  first  wiped  dry  with  the  piece  of  iodoform  gauze  already  mentioned,  and 
then  one  of  the  strips  of  prepared  gauze  is  introduced  into  the  uterus  and  car- 
ried well  up  to  the  fundus  by  means  of  a  Bozeman's  dressing  forceps  or  a 
Kelly's  gauze  packer.  It  must  be  carried  up  into  both  horns  and  the  whole 
cavity  gradually  filled.  The  vagina  is  filled  with  the  remainder  of  the  loose 
gauze  or  with  a  second  five-yard  strip,  which  must  be  packed  firmly  around  the 
cervix.  Iodoform  gauze  is  preferable,  in  spite  of  the  great  opposition  to  its 
odor  and  the  danger  of  iodoform  poisoning,  because  it  becomes  less  foul  in  the 
course  of  twenty-four  to  forty-eight  hours  than  plain  sterile  gauze.  This  is  on 
account  of  the  decomposition  of  iodoform,  by  which  iodine  is  liberated,  this 
31 


466  ABOETioisr. 

being  one  of  our  best  and  least  harmful  antiseptics.  In  cases  of  emergency  a 
roller  bandage  of  gauze,  two  inches  wide,  can  be  boiled  for  five  minutes  in  a 
bichloride  solution  (1 :  1000),  or  a  boric  acid  solution  (1 :  100),  and  thoroughly 
wruns  out.  The  gTeatest  care  should  be  used  not  to  let  the  gauze  touch  any 
part  of  the  body  except  the  vagina  while  it  is  being  introduced.     Iodoform 


Fig.  109. — Specitla  of  V.^kious  Sizes  Adaptable  to  Oxe  Haxdle  Xecessakt  to  Expose  the  Vault 

OF  THE  VaGIXA  AXD  THE  CeRVIX  IX  THE  TrEATMEXT  OF  AX  IxCOMPLETE  AbORTIOX. 

gauze  can  be  allowed  to  remain  in  place  for  two  days  but  one  day  is  sufficient 
in  most  cases.  The  bichloride  gauze  must  not  remain  longer  than  twenty-four 
hours  and  it  should  preferably  be  removed  earliey. 

An  intra-uterine  tampon  should  never  be  used  except  through 
a  speculum  and  under  the  most  stringent  antiseptic  precautions. 
Special  difficulty  will  be  encountered  when  the  uterus  is  unusually  soft  or  retro- 
flexed.  The  introduction  of  the  tampon  must  lie  preceded  by  anteversion  of 
the  uterus,  when  it  can  be  accomplished,  and  the  gauze  packing  must  be  con- 
trolled by  a  hand  on  the  abdomen,  for  much  harm  may  be  done  by  anything 
but  the  most  delicate  manipulations. 


TREATMENT  DURING  PROGRESS  OF  ABORTION.  467 

Massage  of  the  Uterus. — Bimanual  massage  and  expression  accom- 
plishes  for  the  aborting,  non-contracting  uterus  what  Crede's  ''  TIand-griff " 
does  for  the  expression  of  the  placenta  from  the  puerperal  uterus  at  term. 
Hemorrhage  can  quite  often  be  controlled  without  intra-uterine  interference, 
but  expression  of  the  secundines  is  not  often  accomplished  without  it.  The 
method  is  especially  serviceable  when  the  patient  is  bleeding  profusely  and 
nothing  is  ready  for  intra-uterine  treatment. 

Method  of  Massage. — Two  fingers  of  the  right  hand  are  placed  ante- 
rior to  the  cervix  against  the  corpus  uteri  with  the  palmar  surface  forward, 
while  the  left  hand  seeks  the  posterior  wall  of  the  uterus.  The  left  hand 
presses  against  the  finger  in  the  vagina  by  a  rotary  movement ;  it  is  important 
that  the  fingers  in  the  vagina  should  be  kept  absolutely  quiet,  and  especially 
that  no  rubbing  or  boring  motion  should  be  made  with  them.  All  motions 
must  be  made  by  the  external  hand,  the  internal  hand  being  used  as  a  fixed 
point  or  fulcrum.  If  the  whole  of  the  fingers  on  the  external  hand  are  used 
and  the  compressing  force  increased  gradually  and  with  gentleness,  the  patient 
experiences  little  pain  and  makes  little  resistance ;  if,  on  the  other  hand,  only 
the  tips  of  the  fingers  are  used,  the  pain  is  unbearable. 

When  the  hemorrhage  has  been  controlled  by  this  means,  the  uterus  is  well 
contracted,  and  the  secundines  not  expelled,  the  physician  can  proceed  to  attend 
to  the  further  treatment  of  the  case  according  to  the  indications,  at  his  leisure. 

Mechanical  Evacuation  of  the  Contents  of  the  Uterus. — The 
removal  of  the  uterine  contents  is  without  comparison  the  best  treatment  for 
hemorrhage  accompanying  abortion,  but  it  must  be  remembered  that  repeated 
attempts  to  clean  the  uterus  are  fraught  with  great  danger  to  the  patient 
because  of  the  likelihood  of  septic  infection.  Mechanical  evacuation  should 
be  done  thoroughly  and  with  all  the  aseptic  precautions  that  a  conscientious 
practitioner  has  at  his  command.  It  makes  little  difference  whether  it  is  done 
manually  or  instrumentally  so  long  as  it  is  done  thoroughly  and  with  clean- 
liness. In  the  last  month  in  which  abortion  can  occur  (twelfth  to  sixteenth 
weeks)  with  a  dilated  cervical  canal  and  a  soft  uterus,  the  finger  an- 
swers the  purpose,  provided  the  fundus  can  be  reached  by  it  and  the  uterus 
is  freely  movable.  If,  however,  the  fundus  uteri  cannot  be  reached  without 
the  introduction  of  half  the  hand  into  the  vagina,  the  procedure  is  of  doubt- 
ful value.  The  finger  in  the  uterus  should  be  controlled  by  the  hand  on  the 
abdomen,  by  which  the  uterus  is  pushed  down  to  it;  in  this  way  really  good 
contractions  can  be  secured.  Extensively  adherent  particles  of  the  decidua 
and  chorion  are  difiicult  to  reach,  especially  when  they  are  situated  in  the 
horn,  and  such  cases  may  require  instrumental  interference.  Further  advan- 
tages of  the  finger  are  the  positive  knowledge  afforded  by  it  that  nothing 
remains  in  utero ;  the  fact  that  hemorrhage  is  not  excessive  after  its  use,  as 
the  finger  acts  as  a  tampon  to  the  cavity ;  and,  finally,  the  limited  number  of 
instruments  required.  In  the  early  months,  however,  the  finger  is  useless 
unless  the  product  of  conception  has  come  down  into  the  cervical  canal.    Unfor- 


468  ABORTION. 

tmiatelj  tlic  gloved  finger  is  of  no  nse,  because  of  the  lack  of  tactile  sensation, 
while  the  clanger  from  the  septic  finger-nail  in  the  ungloved  finger  cannot  be 
overestimated. 

Extensive  injuries  are  hardly  possible  when  the  finger  alone  is  employed 
to  empty  the  uterus ;  they  generally  arise  from  instrumental  interference, 
whether  by  the  curette  or  the  forceps.  Twenty  inches  or  more  of  intestine 
have  been  drawn  out  through  the  uterus  with  forceps,  and  in  other  cases  the 
omentum  has  been  drawn  into  the  uterus  with  the  curette.  Emulsions  and 
bichloride  of  mercury  solutions  liave  been  poured  into  the  peritoneal  cav- 
ity. This  is  a  good  place  to  emphasize  incidentally  the  importance  of 
sending  immediately  for  an  abdominal  surgeon  when  an  accidental  perfora- 
tion has  occurred.  The  physician  in  charge  of  the  case  should  instantly 
stop  all  attempts  at  further  intra-uterine  work  and  place  an  iodoform  gauze 
tampon  in  the  vagina,  while  waiting  for  the  surgeon.  Instrumental  inter- 
ference under  these  circumstances  is  not  only  admissible,  but  absolutely  indis- 
pensable. 

The  extremes  of  opinion  as  to  the  use  of  the  curette  in  mechanical  evac- 
uation of  the  uterus  are  differently  represented  by  two  observations.  Kneise 
{Miinch.  med.  Wochenschr.,  1903,  Xo.  13)  calls  attention  to  the  fact  that  in 
the  University  Clinic  at  Halle,  only  one  per  cent  of  abortions  required  such 
assistance.  He  reports  five  hundred  cases.  On  the  other  hand,  Dumitriu 
(Erommel's  Jahreshericht,  1905)  reported  that  out  of  one  hundred  abortions 
he  has  used  the  curette  ninety-one  times. 

The  danger  in  using  the  curette  is  not  so  much  from  the  risk  of  perfora- 
tion (provided  it  is  in  careful  and  gentle  hands),  as  it  is  in  failure  to  do  the 
work  thoroughly,  or,  in  other  words,  to  remove  the  secundines.  This  danger 
can  be  avoided  by : 

(1)  A  thorough  understanding  of  the   position   and   size   of  the  uterus. 

(2)  A  thorough  understanding  of  the  consistence  of  the  uterus.  The 
importance  of  this  condition  cannot  be  overestimated.  The  septic  uterus  is 
extremely  soft  and  the  danger  of  perforating  it  necessitates  the  utmost  gentle- 
ness in  the  use  of  the  curette.     Only  one  of  a  large  size  should  ever  be  used. 

(3)  The  administration. of  an  anesthetic. 
(1)   A  most  thorough  asepsis. 

(5)  Such  posture  of  the  patient  that  the  operator's  hands  are  entirely 
free  and  at  liberty  to  work  with  the  greatest  gentleness  compatible  with  rapidity 
and  thoroughness. 

(6)  A  well-dilated   or   dilatable   cervix. 

(Y)  Refraining  from  the  use  of  the  curette  when,  at  the  end  of  the  fourth 
month,  the  whole  placenta  is  in  the  uterus,  and  reliance  instead  upon  the 
dilating  tampon,  the  finger,  and  the  polyp  forceps. 

Method  of  Mechanical  Evacuation. — In  the  majority  of  cases  it 
is  necessary  to  give  an  anesthetic,  but  in  cases  where  this  is  troublesome  or 
impossible,  the  difficulty  may  be  overcome  by  the  administration  of  one-tenth 


TREATMENT    DURING    PROGRESS    OE    ABORTION.  469 

of  a  grain  of  morpliin  liypodermically  just  before  the  mechanical  evacuation. 
The  patient  must  be  thoroughly  cleansed  and  prepared  as  described  under  the 
head  of  uterine  tampons,  after  which  she  must  be  placed  upon  a  table,  not  a 
bed,  with  a  Kelly  pad  under  the  buttocks.  The  field  of  operation  is  thoroughly 
scrubbed  after  the  patient  is  under  the  anesthetic,  and  the  surrounding  parts 
protected  by  sterile  or  bichloride  towels.  The  following  instruments  are  essen- 
tial: A  single-plate  Sims  speculum  (Fig.  109,  p.  466)  to  retract  the  perineum; 
a  bullet  forceps ;  Ellinger's  and  Goodell's  dilators  or  else  steel  sounds  to 
number  thirty-six  (French).  I  have  sometimes  used  Kelly's  urethral  dilators, 
sometimes  with  good  results.  A  well-rounded  sharp  curette  (a  dull  curette 
is  rarely  indicated);  a  placental  forceps;  Fritch-Bozeman's  double  canula 
irrigator,  a  Bozeman's  uterine  dressing  forceps  or  a  Kelly's  gauze  packer, 
and  a  douche  bag. 

Sponge  or  laminar i a  tents  are  rarely  used  to-day;  if  they  are 
employed  they  should  be  enclosed  in  a  thin  rubber  tube  which  is  filled  with 
water  after  its  introduction  into  the  uterus ;  the  upper  end  of  the  tube  should 
be  closed  with  a  string  before  insertion,  while  the  lower  end  is  closed  after  the 
water  is  injected.  By  this  method  of  procedure  most  perfect  asepsis  is  secured. 
After  the  cervix  has  been  exposed  by  the  speculum,  and  drawn  towards  the 
pubes  with  the  bullet  forceps,  the  canal  is  dilated,  if  necessary.  When  the 
abortion  is  one  of  less  than  ten  weeks,  the  curette  can  be  introduced  immedi- 
ately after  the  dilatation  and  the  uterus  cleaned  by  gentle  motion  from  above 
downwards.  The  physician  should  accustom  himself  to  curetting  the  cavity  in 
regular  order,  thus :  the  posterior  wall,  the  anterior  wall,  the  left  side,  the  right 
side,  and  the  horns  should  be  scraped  in  the  order  given.  After  the  twelfth 
week  the  curette  is  apt  to  slide  down  the  membranes,  and  it  will  be  necessary 
to  use  a  large  placental  forceps  with  dull  edges  to  start  the  placenta,  after  which 
the  curette  can  be  used  to  finish  the  work.  Under  all  circumstances  the  curet- 
ting must  be  done  with  thoroughness,  after  which  the  cavity  is  irrigated  with  a 
sterile  normal  salt  solution,  or  a  solution  of  bichloride,  1 :  5000,  great  care 
being  taken  that  there  is  a  free  flow  from  the  canula  or  the  uterus.  The  mo- 
ment the  flow  stops,  the  instrument  should  be  withdrawn. 

In  an  abortion  during  the  early  months  a  strip  of  gauze  should  be  placed 
in  the  uterus,  reaching  up  to  the  fundus,  and  removed  in  twenty-four  hours. 
If  the  case  is  late  in  the  fourth  month  the  cavity  should  be  well,  but  not 
rudely  packed,  and  a  second  strip  used  to  fill  the  vagina.  This  procedure  not 
only  stops  hemorrhage  but  sets  up  firm  contractions,  drains  the  uterus,  and 
assists  in  a  prompt  involution  of  the  organ.  The  gauze  is  removed  in  twenty- 
four  hours.  A  large  dose  of  ergot  or  gossypium  will  assist  materially  in  assur- 
ing a  firm  contraction.  Three  large  doses  of  one  teaspoonful  each  may  be  given 
on  the  day  after  operation,  four  hours  apart.  Quinine  has  been  reported  as 
giving  excellent  results  as  a  uterine  contractor ;  it  should  be  given  in  solution 
every  ten  minutes,  but  not  more  than  two  or  three  doses  in  one  day  (Walther, 
Zeitsch.  f.  Arzt.  Fort.,  1903,  ^o.  20-21). 


470  ABORTION. 

Special  precautions  must  be  employed  in  the  case  of  the  retroflexed,  fixed, 
soft,  friable  uterus  and  in  one  which  is  acutely  inflamed.  The  latter  will  be 
spoken  of  under  the  head  of  septic  abortions. 

After-treatment. — It  is  wise  to  keep  the  patient  in  bed  for  from  six  to  ten 
days.  All  douches  and  local  interference  of  any  kind  should  be  avoided,  unless 
some  special  indication  arises,  as  unnecessary  and  therefore  useless.  The 
patient  must  be  kept  clean  and  a  vulvar  pad  should  be  worn.  For  urination 
and  defecation  a  commode  may  be  used,  if  she  is  able  to  sit  up  at  all;  the 
urine  should  not  be  drawn  if  it  can  possibly  be  voided,  for  fear  of  a  septic 
cystitis.  Before  the  patient  gets  up,  it  is  wise  for  the  physician  to  assure  him- 
self of  the  proper  involution  of  the  uterus,  taking  into  account  the  time  since 
the  abortion  took  place.  If  the  uterus  is  not  in  proper  condition  suitable 
treatment  should  be  instituted. 


SEPTIC    ABORTION. 

One  of  the  most  serious  complications  arising  from  abortions  is  the  septic 
or   sapremic    condition. 

By  septic  abortion  is  meant  an  infection  of  the  uterine  cavity  and  its 
contents  with  pathogenic  germs,  with  the  production  of  fever  and  possibly 
chills.  It  is  one  of  the  most  frequent  conditions  met  with  and  is  commonly 
the  result  of  criminal  intent.  Olshausen  attributes  eighty  per  cent  of  all  sep- 
tic abortions  to  criminal  interference.  I  might  mention  the  fact  that  when 
I  was  a  student  I  was  much  impressed  by  something  said  to  me  by  my 
preceptor,  namely,  that  he  had  never  seen  a  woman  die  from  a  septic  abor- 
tion due  to  natural  causes,  but  that  he  had  seen  many  die  from  criminal 
interference.  This  was  in  the  days  when  physicians  rarely  interfered  in  the 
normal  mechanism  of  abortion,  except  to  remove  from  the  cervix  what  had 
been  forced  into  it  by  the  uterus.  Septic  abortion  is  less  frequent  in  women 
of  middle  life  than  in  the  young,  a  fact  easily  explicable  by  the  more  deli- 
cate fabric  of  the  tissues  in  youth.  The  same  thing  is  true  of  septic  peri- 
tonitis, due  to  the  fact  that  there  are  fewer  lymphatics  in  the  old  than  in 
the  young. 

The  sapremic  condition  is  not  very  frequent.  It  should  be  treated 
by  the  establishment  of  thorough  drainage  and  prompt  removal  of  the  decom- 
posing uterine  contents  as  already  described  (see  mechanical  and  manual 
evacuation  of  uterus).  It  is  hardly  necessary  to  say  that  j^erfect  asepsis  is 
essential  to  success. 

The  treatment  of  septic  abortion  in  the  early  stages  is  the  same 
as  that  just  mentioned.  It  will  be  wise  to  place  the  patient  on  a  liquid  diet 
as  long  as  there  is  much  fever.  An  ice  bag  above  the  pubes  is  good  as  long 
as  the  temperature  is  above  101°  F. ;  a  towel  should  always  be  placed  between 
the  ice  bag  and  the  skin.  While  the  cold  is  pleasant  to  the  patient  as  long  as 
there  is  fever,  the  reverse   obtains  when  the  temperature  is  below  the  point 


SEPTIC    ABOETIOlSr.  471 

just  given.  To  carry  out  this  treatment  properly  the  temperature  should  be 
taken  every  three  hours ;  a  rectal  temperature  is  the  only  safe  one  to  take. 
If  the  towels  are  constipated  a  saline  cathartic  will  relieve  the  patient.  The 
greatest  care  will  have  to  be  exercised  in  all  manipulations  when  the  process 
has  advanced,  on  account  of  the  softening  of  the  uterus  or  its  surrounding 
tissue.  Lymphangitis  and  phlebitis  are  common  complications ;  tubal 
and  ovarian  abscesses  also  occur,  but  less  frequently,  unless  the  case  is 
of  a  gonorrheal  character.  When  these  complications  occur  the  treatment 
already  described  is  not  sufficient  and  therapeutic  measures  suited  to  the  spe- 
cial indications  must  be  adopted. 

When  the  abortion  occurs  during  the  earlier  months  and  there  is  little  peri- 
uterine complications,  an  injection  of  a  ten  per  cent  mixture  of  iodoform 
in  glycerin  should  be  made  into  the  uterine  cavity  through  a  small  soft- 
rubber  catheter  and  a  glass  syringe,  and  the  vagina  filled  with  iodoform  gauze. 
The  catheter  should  be  small,  and  an  easy  outflow  of  the  mixture  should  be 
assured ;  a  solid  tube  must  never  be  used  for  the  purpose.  The  injection  should 
be  made  slowly  and  without  any  force. 

If  the  case  has  arrived  at  or  near  the  fourth  month  and  the  septic  process 
is  kept  up  by  particles  of  dead  matter,  or,  in  other  words,  the  pathogenic 
organisms  are  fed  by  them,  I  would  recommend  an  intermittent  alcohol  intra- 
uterine injection  as  by  far  the  best  mode  of  treatment.  It  is  absolutely  harm- 
less and  easy  of  application  even  by  the  most  inexperienced,  after  the  drain  has 
once  been  into  the  uterus,  and  it  disturbs  the  patient  to  but  a  slight  extent,  as 
after  the  first  application  she  is  not  again  removed  to  a  table.  Besides  the 
instruments  enumerated  (see  p.  469)  the  operator  must  have  a  soft  round 
catheter  (No.  20,  French)  to  which  is  fastened  by  a  glass  joint  another  tube 
about  sixteen  inches  long,  armed  with  a  small  glass  funnel  or  the  barrel  of  a 
glass  syringe.  Two  pieces  of  string  about  sixteen  inches  long  a^e  boiled  with 
the  rest  of  the  instruments.  The  patient  is  prepared  as  already  described,  and 
the  operator  proceeds  as  in  evacuation  of  the  uterus  until  he  arrives  at  the 
introduction  of  the  gauze.  He  then  takes  a  careful  measurement  of  the  depth 
of  the  uterus  and  ties  a  string  with  a  clove  hitch  to  the  portion  of  the  catheter 
which  will  be  exposed  just  outside  the  cervix  when  the  instrument  is  inserted 
into  the  uterus  as  high  as  the  fundus.  The  catheter  is  introduced  into  the 
uterus  up  to  the  fundus  and  a  small  strip  of  gauze  packed  up  into  the  uterus 
as  far  as  each  horn.  The  string  spoken  of  is  then  tied  to  the  gauze  strip  and 
the  vagina  packed  with  the  remainder  of  the  gauze.  The  purpose  of  the  string, 
which  ties  the  gauze  to  the  catheter,  is  to  prevent  the  catheter  being  pulled  out 
by ,  accident,  for  if  this  were  to  occur,  it  would  be  necessary  to  remove  the 
gauze  in  the  vagina.  The  rubber  tube  with  the  funnel  is  fastened  to  the 
catheter  and  a  twenty-five  per  cent  solution  of  alcohol  poured  into  the  catheter 
through  the  funnel,  until  it  begins  to  flow  from  the  vagina.  This  douche  must 
be  repeated  every  two  hours.  In  private  practice  among  the  less  fortunately 
situated,  where  no  trained  nurse  is  at  hand,   the  physician  should  make  the 


472 


ABORTION. 


folloAving  arrangements.     He  must  prescribe  a  quart  bottle  of  the  solution  of 
alcohol : 

^   Spirit,  vini one  part  =^  250.0 

Aquffi three  parts  =  750.0 

M. 

He  should  give  the  attendant  an  empty,  clean,  two-ounce  bottle  and  direct  her 
to  fill  it  with  the  dilute  alcohol  and  pour  it  into  the  funnel  every  two  hours. 
The  funnel  and  tube  are  placed  on  a  clean  towel  on  the  patient's  abdomen 
and  held  there  by  a  binder.  The  apparatus  does  not  annoy  the  patient  and 
she  does  not  have  to  remain  flat  on  her  back.  The  only  pain  produced  by  the 
treatment  is  that  caused  by  the  first  flow  of  alcohol  over  the  perineum.  The 
catheter  should  remain  in  the  uterus  for  five  days,  unless  the  temperature  falls 
below  101°  F.,  taken  in  the  rectum,  but,  as  it  drops,  the 
injections  are  given  less  frequently.  When  the  temperature 
has  remained  below  101°  F.  for  twenty-four  hours,  the  dress- 
ing may  be  removed.  If  there  is  no  improvement  in  the 
septic  condition  during  the  first  twenty-four 
hours  there  is  probably  some  abnormal  con- 
dition outside  the  uterus. 

By  means  of  these  injections  the  endo- 
metrium is  constantly  bathed  in  a  twenty-five 
per  cent  solution  of  alcohol.  The  gauze  is  the 
agent  which  carries  it  through  the  cavity  of 
the  uterus  and  is  itself  constantly  kept  clean 
by  the  fluid.  A  second 
string  is  fastened  to  the 
catheter  and  cut  short  at 
the  vulva — it  is  simply 
a  mark  to  show  that  the 
catheter  is  not  displaced. 
I  have  always  used  this 
method  for  over  ten  years 
and  have  never  seen  any 
evil  results  from  it;  on 
the  contrary,  it  has  done 
much  good.  The  earlier 
it  is  used  in  the  disease 
the  more  satisfactory. are 
the  results.  When  there 
is  already  extensive  dis- 

FiG.  110.— Method  OF  Irrigating  THE  Infected  Uterine  Cavity.  ease,  palpable    or    otlier- 

The  catheter  is  placed  within  the  uterus,  together  with  the  drain-  "wise  OUtside    of    the   Ute- 

age  pack.    By  attaching  a  funnel,  as  shown,  alcohol  (25  per  cent)                  '  . 

can  be  introduced  into  the  uterus  as  a  disinfectant.  rilS,  the     result     IS     lesS 


ARTIFICIAL    ABOKTION.  473 

satisfactory.  Figure  109  shows  the  method  in  action.  The  thumb-screw  near 
the  funnel  is  placed  there  to  keep  the  tube  full  of  the  dilute  alcohol  and  facili- 
tate its  flow  by  gravity  when  the  funnel  is  filled  and  the  thumb-screw  opened. 
If  this  treatment  is  pursued  in  the  later  months  of  pregnancy  a  small-sized 
stomach-tube  answers  the  purpose. 

Extensive  peri-uterine  disease,  when  it  exists,  must  be  met  by 
such  treatment  as  has  been  described.  Extirpation  of  the  uterus  has  not  met 
with  much  encouragement.  If  the  sepsis  is  still  confined  to  the  womb,  it  is 
hardly  justifiable,  wliile  if  the  infection  has  gone  beyond  the  uterus,  it  is  useless. 

Hemorrhage  and  sepsis  are  not  the  only  indications  for  evacuation  of  the 
uterus,  although  they  are  all  that  have  been  discussed.  A  woman  cannot  be 
allowed  to  go  on  indefinitely  with  retained  secundines,  simply  because  they 
produce  no  dangerous  symptom.  The  constant  loss  of  blood,  the  inability  for 
exertion,  the  annoyance  induced  by  the  uncertainty  of  the  future,  and  the  con- 
venience of  her  physician,  are  all  factors  to  be  considered,  always  provided 
that  the  death  of  the  fetus  is  certain. 


CRIMINAL    ABORTION. 

In  criminal  abortion,  mechanical,  electrical,  and  medicinal  agents 
are  all  employed.  So  far  as  the  moral  aspects  of  the  question  are  concerned 
they  are  equally  bad ;  so  far  as  the  injurious  effects  upon  the  woman  are  con- 
cerned, the  medicinal  are  the  least  harmful  and  least  successful,  while  the 
mechanical  method  of  thrusting  a  sound  into  the  uterus  affords  the  greatest 
risk  of  sepsis.  The  criminal  abortionist  often  combines  the  electric  method 
with  the  mechanical  one,  in  which  case  he  is  apt  to  get  the  ill  effects  of  the 
latter.  To  what  extent  the  medical  profession  is  responsible  for  the  murder 
of  the  unborn  is  shown  by  the  fact  that  women  often  use  gum  catheters  them- 
selves and  are  sufiiciently  Avell  posted  to  boil  them  before  their  insertion.  The 
punishment  of  such  criminals  is  always  difficult,  as  popular  sympathy  is  rather 
with  the  abortionist  and  murderer,  and  the  witness  is  apt  to  be  an  unwilling  one. 

ARTIFICIAL    ABORTION. 

When  the  continuance  of  pregnancy  threatens  life,  the  claims  of  the  mother 
have  a  prior  right  to  consideration  and  it  is  the  duty  of  the  medical  attendant 
not  only  to  suggest,  but  to  urge  its  termination.  The  following  conditions  jus- 
tify the  induction  of  abortion: 

(1)  Pernicious  vomiting. 

(2)  Acute  Bright's  disease. 

(3)  Certain  grave  constitutional  diseases,  which  must  end  fatally  in  the 
near  future. 

(4)  Eclampsia. 

(5)  Severe  pyelitis. 


474  ABORTION. 

Pernicious  vomiting  is  one  of  the  most  important  indications  for  the 
induction  of  artificial  abortion,  and  when  its  existence  can  be  clearly  shown, 
the  pregnancy  should  be  promptly  brought  to  an  end.  ]^ot  all  forms  of 
troublesome  and  persistent  vomiting,  however,  are  pernicious,  and  it  is  most 
important  to  distinguish  between  the  real  pernicious  variety  and  that  which  is 
only  an  exaggeration  of  the  nausea  which  is  one  of  the  commonest  accompani- 
ments of  pregnancy.  When  the  patient  vomits  persistently  at  intervals  all 
day  and  all  night,  the  vomiting  being  associated  with  the  ejection  of  bile ; . 
when  the  condition  becomes  so  aggravated  that  no  food  whatever  is  retained, 
and  the  patient's  strength  is  so  exhausted  that  she  is  confined  to  bed  for  the 
greater  part  of  the  time;  and  when  this  condition  of  things  has  lasted  for 
from  ten  days  to  a  fortnight,  it  is  almost  certainly  pernicious. 

In  all  cases  of  severe  nausea  it  is  extremely  important  to  determine  the 
relationship  of  the  ammonia  output  during  pregnancy  to  the 
total  amount  of  nitrogen  in  the  urine.  The  proteids  of  the  food  are 
the  source  of  the  nitrogen,  and  nitrogenous  waste  products  represent  proteid 
waste.  The  average  waste  in  the  ordinary  individual  is  fifteen  grains  in  twenty- 
four  hours.  It  is  most  important  to  remember  that  the  clinical  manifestations 
are  not  necessarily  in  proportion  to  the  increase  of  ammonia  output.  In  neurotic 
women,  vomiting  may  be  excessive  with  little  or  no  increase  in  the  proportion 
of  ammonia,  whereas  in  other  cases  where  vomiting  is  comparatively  slight, 
the  ammonia  output  is  dangerously  large.  The  necessity  for  inducing  abortion 
must  be  decided  solely  by  the  increase  of  ammonia,  and  whenever  this  rises 
above  ten  per  cent  the  uterus  must  be  relieved  of  its  contents  without  delay. 
To  ascertain  the  point  positively,  a  careful  chemical  analysis  must  be  made, 
determining  the  relation  between  the  ammonia  and  the  total  amount  of  nitro- 
gen in  the  urine.  If  the  physician  is  at  a  distance  from  a  chemical  laboratory, 
he  should  take  six  ounces  of  the  urine,  add  to  it  a  teaspoonful  of  chloroform, 
and  send  it  to  the  nearest  well-equipped  laboratory. 

Acute  Bright's  disease  undoubtedly  affords  an  urgent  reason  for 
emptying  the  uterus,  and  whenever  there  is  the  slightest  suspicion  of  the  pres- 
ence of  a  nephritis  its  existence  or  non-existence  must  be  determined  without 
a  moment's  unnecessary  delay. 

In  grave  constitutional  disorders  which  may  end  fatally  it  is  the 
prerogative  of  the  mother  to  decide  whether  or  not  she  will  go  through  with 
the  pregnancy.  Such  diseases  are:  Aneurism,  cerebral  disease,  car- 
diac  disease,    a   rapidly    advancing   phthisis,    etc. 

Eclampsia. — This  condition  occurring  at  any  time  during  pregnancy 
constitutes  an  urgent  reason  for  inducing  abortion. 

Pyelitis. — A  mild  case  of  pyelitis  is  often  relieved  by  rest  in  bed, 
urotropin,  and  drinking  large  quantities  of  water.  In  some  cases 
excellent  results  have  been  obtained  by  catheterization  of  the  kidney 
and  irrigation  of  the  pelvis.  In  more  severe  cases,  however,  with  a 
large  amount  of  pus,  fever,  and  perhaps  pain  in  the  kidney,  the  only  pos- 


ARTIFICIAL    ABOKTION.  475 

sible  treatment  is  the  induction  of  abortion,  which  in  many  cases  gives  prompt 
relief. 

In  addition  to  the  cases  which  come  under  one  of  these  five  fundamental 
indications,  the  advice  of  the  medical  man  may  occasionally  be  sought  under 
circumstances  of  a  special  character.  For  example,  he  may  be  urged  to  induce 
an  abortion  in  the  case  of  an  illegitimate  pregnancy,  and  here  it  is  his  duty 
to  give  an  unqualified  refusal,  no  matter  how  pitiful  the  circumstances  may  be, 
nor  how  strong  the  reasons  for  "  saving  a  young  girl's  reputation."  Again, 
he  may  be  importuned  by  a  wife  worn  out  by  frequent  child-bearing  and 
dreading  the  exhaustion  consequent  upon  another  pregnancy  and  labor,  with 
the  added  fatigue  of  lactation  and  of  caring  for  another  infant.  'No  matter 
what  reasons  may  be  brought  to  bear,  the  upright  physician  must  maintain 
the  principle  that  in  entering  upon  the  married  state,  husband  and  wife  cov- 
enant to  bear  the  burdens  it  naturally  imposes,  and  to  make  such  sacrifices  as 
are  demanded  by  proper  standards  of  right,  clean  living,  even  at  the  expense 
of  loss  of  health,  as  well  as  of  plans  and  social  opportunities  upon  which  their 
hearts  may  be  set.  The  position  of  a  husband  and  wife  who  have  a  young 
family  to  support  and  look  forward  with  anxiety  to  an  additional  burden  when 
strength  and  means  are  already  taxed  to  their  utmost,  is  a  sad  one,  and  the 
duty  of  the  family  physician  is  not  confined  to  a  refusal  to  consider  the  ques- 
tion of  an  abortion.  He  should  step  in  as  a  friend  as  well  as  a  medical  adviser, 
using  all  his  influence  to  dissuade  the  parties  concerned  from  a  measure  so 
fraught  with  peril  to  the  moral  nature,  as  well  as  to  health  and  even  life,  try- 
ing further  to  persuade  them  to  take  a  wider  view  of  such  an  act  in  its  relation 
to  the  character  of  the  individual  and  to  the  community  at  large. 

Method  of  Artificial  Abortion. — When  the  preservation  of  either  the  health 
or  life  of  a  woman  is  at  stake,  it  is  not  only  justifiable,  but  absolutely  obliga- 
tory, to  interrupt  a  pregnancy.  This  should  be  carried  out  with  the  greatest 
care  in  order  to  escape  the  dire  results  of  hemorrhage  and  infection  so  common 
after  improper  and  careless  work.  The  two  chief  things  are  to  comply  with 
perfect  asepsis  and  to  effect  a  complete  dilatation  of  the  cervix.  Unless  the 
operation  meets  these  two  cardinal  prerequisites  it  should  not  be  done.  Perfect 
asepsis  guards  against  infection  and  a  complete  dilatation  of  the  cervix  makes 
possible  a  control  of  hemorrhage  which  otherwise  may  be  very  severe.  To 
be  compelled  to  rapidly  dilate  a  cervix  to  relieve  a  dangerous  hemorrhage  due 
to  abortion  is  a  very  unpleasant  task.  Such  is  the  condition  frequently  met 
with  where  abortions  have  been  caused  by  introducing  a  sound  into  the  uterus. 
The  friability  of  the  cervix  and  the  resulting  tears  are  astonishingly  common. 
Happily,  the  vaginal  C?esarean  section  introduced  by  Dlihrssen  gives  us  an 
alternative  in  these  cases.  I  advise  it  in  all  cases  where  a  rapid  dilatation 
is  necessary,  as,  for  example,  in  a  placenta  prawia. 

An  effectual  and  simple  method  of  causing  abortion  is  as  follows :  The 
patient's  vulva  and  surrounding  parts  are  carefully  shaved,  cleansed  with  soap 
and  water,  and  sterilized  with  alcohol  and  1-1,000  bichloride  solution.     The 


476  ABOKTION. 

patient  is  then  put  in  the  Sims  left  lateral  posture,  the  perineum  is  retracted 
Avith  a  speculum,  and  the  cervix  grasped  with  tenaculum  forceps.  The  vagina 
is  then  cleansed  with  a  tincture  of  green  soap  and  water,  ninety-five-per-cent 
alcohol,  ether,  and  1-1,000  bichloride  solution,  after  which  it  is  carefully 
dried  out.  A  large  male  rubber  catheter,  which  has  been  sterilized  by  boiling, 
is  then  introduced  well  up  into  the  uterus;  the  vagina  about  the  catheter  is 
loosely  packed  with  sterile  gauze.  All  of  this  can  be  carried  out  without 
any  anesthesia,  in  the  patient's  bed  or  in  the  operating  room.  The  patient 
is  then  kept  in  bed,  and,  as  a  rule,  within  twenty-four  hours  the  cervix  will 
be  completely  dilated  and  the  abortion  over.  Prior  to  the  third  month  the 
abortion  is  frequently  incomplete,  later  it  is  nearly  always  complete.  Indeed, 
after  the  third  month  a  complete  abortion  usually  results  from  merely  dilating 
the  cervix,  rupturing  the  membranes,  and  allowing  the  escape  of  the  con- 
tained amniotic  fluid.  When,  after  a  complete  dilatation  of  the  cervix,  there 
is  evidence  that  the  ovum  or  parts  of  it  have  not  come  away,  as  indicated  by 
bleeding  or  continued  pain,  the  jDatient  should  be  anesthetized,  put  in  the 
perineal  posture  on  an  operating  table,  and  the  ovum  separated  from  the  ute- 
rus by  the  finger  introduced  through  the  cervix.  The  hand  during  this  pro- 
cedure should  always  be  covered  with  a  thin  rubber  glove.  The  finger  can 
often  be  supplemented  by  the  use  of  the  placental  forceps  and  the  dull  curette. 
Instruments  should  be  employed,  however,  with  the  greatest  care,  and,  as  a 
rule,  the  finger  is  all  that  is  necessary.  At  the  conclusion  of  the  removal  the 
entire  uterine  cavity  should  be  carefully  gone  over  by  the  finger.  If  this 
precaution  is  not  taken,  pieces  of  placenta  or  membranes  will  frequently  be 
left  in,  however  careful  the  operator  may  be.  In  one  case  a  competent  obstet- 
rician of  my  acquaintance,  after  doing  what  he  considered  a  complete  abortion, 
was  distressed  to  have  his  patient  showing  signs  of  further  trouble.  At  a 
second  operation  he  discovered  that  he  had  left  twin  foeti  in  the  uterus,  having 
neglected  to  palpate  with  the  finger. 

At  the  conclusion  of  the  removal  of  the  ovum  the  uterus  can  with  advantage 
be  washed  out  with  hot  sterile,  normal  salt  solution.  If  there  is  still  hemor- 
rhage, which  is  infrequent,  the  uterus  should  be  packed  with  an  iodoform 
gauze  pack,  to  be  removed  in  twenty-four  hours.  x\.fter  removal,  full  doses  of 
ergotol  are  of  advantage  in  bringing  about  a  contraction  of  the  uterus  and  a 
cessation  of  the  hemorrhage. 


CHAPTER    XIX. 

INJURIES  AND   AILMENTS   FOLLOWING  LABOR. 

Importance  of  prophylaxis,  p.  477.  Sequelae  of  labor:  Physiological,  p.  477;  abnormal  and 
pathological,  p.  478.  _  Prevention  of  sequelae:  Use  of  forceps,  p.  482;  protection  of  perineum, 
p.  483;  repair  of  perineum,  p.  484;  repair  of  cervix,  p.  486;  precautions  against  infection, 
p.  486;  use  of  catheter,  p.  486;  choice  of  nurse,  p.  487. 

Inasmuch  as  a  large  number  of  gynecological  affections  date  from  child- 
birth,  there  is  manifestly  a  wide  field  for  the  exercise  of  prophylaxis  in  obstet- 
rics. The  prevention  of  a  large  amount  of  serious  gynecological  work  lies  in 
the  hands  of  the  general  practitioners  who  are  caring  for  women  in  childbirth 
to-day.  May  I  add  that  it  is  a  far  higher  function  of  the  profession  to  prevent 
a  thousand  cases  of  rupture  of  the  perineum  than  to  cure  the  same  number  by 
appropriate  surgical  operations,  however  brilliant  or  however  praiseworthy  the 
latter  may  be. 

SEQUELS    OF    LABOR. 

Labor  is  a  physiological  process ;  therefore,  if  the  mother  is  in  good  health, 
if  her  pelvis  is  normal,  and  her  tissues  in  good  condition,  she  should  rise  up 
from  her  bed  a  perfectly  sound  woman,  provided,  of  course,  that  the  child  pre- 
sents no  abnormality,  and  that  the  labor  has  been  well  conducted.  Even  in  a 
perfectly  normal  labor,  however,  certain  slight  injuries  and  changes  are  liable 
to  occur  of  so  slight  a  character  that  they  may  be  regarded  as  physiological. 

The  physiological  sequelae  observable  after  a  normal  labor  are : 

A  large  uterus  beginning  to  contract,  with  a  raw  inner  surface,  pouring 
out  the  lochia. 

A  fresh  lacerated  wound  of  the  cervix. 

A  lax,  distended  vagina. 

A  lax,  distended,  and  everted  vaginal  orifice,  with  fissures  extending  to  the 
hymen. 

A  laceration  of  the  perineum,  superficial  in  extent,  with  one  or  two  super- 
ficial branches  running  into  the  vaginal  sulci. 

Dilatation  and  eversion  of  the  rectum  with  dilatation  of  its  veins,  most 
frequently  seen  in  multipara. 

A  slight  bilateral  laceration  of  the  cervix. 

A  slight  hypertrophy  of  the  uterus. 

A  widening  of  the  vagina,  with  tears  in  the  region  of  the  hymen,  and  a 

slight  laceration  of  the  vaginal  introitus. 

477 


478 


INJURIES    AND    AILMENTS    FOLLOWING    LABOE. 


The  abnormal  and  pathological  sequelae  of  labor  are: 

Mechanical  injnries,  such  as  tears  or  ruptures,  relaxations,  sloughs,  retro- 
flexion, descensus,  and  prolapse. 

Infections  of  both  the  upper  and  lower  genital  tracts,  including  the  uterine 
tubes,  the  uterus,  the  cervix,  the  pelvic  cellular  tissue,  the  vagina,  and  tlie 
perineum,  as  well  as  the  bladder.     Venous  thrombosis  in  the  broad  ligaments. 

JN^erve  exhaustion. 

Toxemias  resulting  in  Bright's  disease  and  its  sequelae. 

These  pathological  sequelae  result  in  a  variety  of  gynecological  con- 
ditions, which  make  themselves  first  known  months,  or,  it  may  be,  years  later. 

The  mechanical  injuries  cause  deep  lacerations  of  the  cer- 
vix,   extending  down  onto  the  lateral  walls,  in  the  form  of  falciform  scars, 


Fig.  111. — One  of  the  Rarer  Injuries  following  Labor  is  a  Cervico- vaginal  Fistula.     This  is 
most  frequently  found  after  an  unsuccessful  attempt  to  denude  and  unite  the  torn  cervical  lips. 


which  serve  to  fix  the  uterus  to  the  pelvic  wail.  Rarely  the  cervix  survives  the 
injury  with  a  fistula  in  one  side  (see  Tig.  111).  As  a  rule  a  defect  such  as 
that  seen  in  the  illustration  is  due  to  an  attempted  closure  of  a  central  tear, 
which  has  not  resulted,  successfully.  Radiating  scars  are  found  at  the  pelvic 
outlet,  beginning  in  the  perineum  and  extending  upwards  in  a  "  Y  "  shape 
into  the  right  and  left  sulci.     In  rare  instances,  the  perineum  is  simply  in- 


MECHANICAL    INJURIES    CAUSED    BY    LABOR. 


479 


filtrated,  and  still  more  rarely,  the  child  is  born  per  anum.  The  extreme  form 
of  injury  at  the  pelvic  outlet  is  a  complete  tear  (see  Fig.  112)  dividing 
the  septum  between  the  rectum  and  the  vagina  and  throwing  both 
outlets  into  one  common  cloaca.  Among  the  tears  which  eventually  become 
serious  in  their  consequences,  but  are  often  not  perceptible  at  the  time  they  are 


'-•# 


^rf» 


A 


■<* 


Fig.  112. 


-ACoMPLETK  Tkah  ,Sii(n\-ixc;  A  Characteristicat.i.y  Pi:\rA(;i)XAi.  InitM. 
triangular.     The  pits  of  the  torn  sphincters  are  seen  at  the  sides. 


Sometimes  this  is 


made,  is  the  injury  received  from  the  separation  of  the  attachments 
of  the  levator  ani  muscle  from  the  rectum.  This  injury,  associated 
as  it  is  with  the  tear  of  the  perineum,  results  in  an  entire  loss  of  support  to 
the  lower  part  of  the  bowel,  with  the  formation  of  a  rectocele,  or  the  eversion 
of  the  lower  vaginal  wall.  The  outlet  thus  presents  an  appearance  described 
as  relaxed  (see  Fig.  113).  The  relaxed  outlet  is  recognized  by  the 
vertical  direction  of  the  levator  fibres,  just  behind  the  pubic  arch,  replacing 
the  strong  band  felt  when  the  posterior  vaginal  wall  is  lifted  up  in  the  unbroken 
ring.  It  is  a  good  plan,  in  order  to  be  precise  as  to  the  degree  of  the  breaking 
down  of  the  outlet,  to  use  an  instrument  like  that  shown  in  the  figure  (see 
Fig.  114).  By  separating  its  blades  to  a  maximum  without  using  more  than 
slight  force,  the  degree  of  relaxation  is  read  directly  in  centimetres  from  the 
scales  attached  to  the  handles  of  the  calibrator. 

An   infection   acquired  in  the  act  of  childbirth  may  spread  so  extensively 
that,  if  the  patient  survives,  she  recovers  only  with  the    uterine    tubes    ad- 


480 


IISTJUKIES    AND    AILMENTS    FOLLOWING    LABOR. 


lierent  or  distended  with  pus;  with  an  Gndometritis  of  the  body 
of  the  uterus;  with  an  infection  of  the  cervical  glands  (endocervi- 
citis)  ;  a  troublesome  vaginitis;  an  infection  of  the  vulvo-vaginal 
glands ;    or    a    cystitis. 

Complete  exhaustion  of  the  nervous  system  is  sometimes  seen  in 
a  patient  who,  without  any  serious  apparent  injurj^,  has  passed  through  her 
confinement  as  an  o^^erwhellning  experience,  requiring  the  expenditure  of  all 


Fig.  113. — A  i  yric  allt  Relaxed  Vaginal  Otjtlet.  The  perineum  Is  well  preserved,  but  it  is  e\ddent 
that  the  structures  above  have  no  support  and  the  anterior  and  posterior  walls  are  rolling  out.  Note, 
too,  the  flattening  of  the  cleft  at  this  point. 


her  individual  nerve  force ;  and,  like  a  plant  which  is  capable  of  producing  but 
one  flower  and  then  goes  to  seed,  she  remains  exhausted  for  years  or  even  for 
her  whole  remaining  lifetime.     It  is  often  seen  in  women  who  have  borne  a 


PREVENTION    OF    SEQUEI^iE. 


481 


number  of  children  in  rapid  succession.     The  demands  made  hj  lactation  also 
induce  nervous  exhaustion  in  many  women. 

Combinations    of    these    sequelae    are  often  seen.     Tor  instance,  a 
patient  has  extensive  laceration  of  the  cervix  and  of  the  vaginal  vault;  or  an 


Fig.  114. — A  Vaginal  Outlet  Calibrator.  This  instrument  measures  the  size  of  the  vaginal  outlet  on 
the  grackiated  rod,  as  the  handles  are  squeezed  together  with  gentle  force,  separating  tlie  distal  end 
of  the  instrument  until  resistance  is  experienced. 


infection  of  the  uterine  tubes  v^ith  a  retroflexed  adherent  uterus ;  or  a  vesico- 
vaginal fistula  due  to  sloughing  of  the  anterior  vaginal  wall  with  a  complete 
tear  of  the  perineum ;  or  nervous  exhaustion  with  more  or  less  extensive  mechan- 
ical injury. 

PREVENTION    OF    SEQUELS. 

If  the  general  practitioner  who  attends  obstetrical  cases  could  anticipate 
and  prevent  these  injuries,  gynecological  work  would  be  greatly  reduced  and 
largely  limited  to  the  treatment  of  venereal  diseases,  tuberculosis,  and  tumors. 
Prevention  does  undoubtedly  lie  to  a  great  extent  within  the  power  of  the 
medical  attendant  at  obstetrical  cases,  for  the  following  conditions  are  more  or 
less  completely  under  his  control : 

(1)   He  can  often  prevent  mechanical  injuries,  or  obviate  any  ill  conse- 
quences by  their  immediate  repair. 
32 


482  IX JURIES    AXD    AILMEXTS    FOLLOWIXG    LABOE. 

(2)  lie  can,  as  a  rule,  prevent  an  infection  bv  bis  aseptic  conduct  of  tbe 
labor. 

(3)  He  can  lessen  exbaustion  bj  timely  and  skilful  interference. 

To  effect  tbese  ends  obstetrics  must  be  regarded  as  tbe  one  brancb  of  medi- 
cine "u-bicb  constitutes  a  universal  specialty  for  all  pbysicians  in  general  prac- 
tice, and  obstetrical  cases  must  be  taken  more  seriously  tban  is  tbe  fasbion 
to-day.  Tbe  man  wbo  assumes  tbe  cbarge  of  an  obstetrical  case  must  never  get 
into  a  burry  to  bave  it  over ;  be  must  be  vrilling  to  spend  bis  time  at  tbe  bedside 
of  bis  patient,  and  to  wait  as  long  as  may  l^e  necessary  for  tbe  T\'eal  of  tbe 
belpless  Avoman  ^vbo  trusts  ber  life  and  ber  bealtb  to  bis  care.  He  ougbt  to  l3e 
^vell  skilled  in  tbe  use  of  tbe  obstetric  forceps  and  to  be  fully  convinced  tbat 
tbeir  use  may  be  a  great  evil  as  well  as  a  great  boon  to  a  v^oman  in  tbe  tbroes 
of  cbildbirtb.  To  make  tbe  best  use  of  tbe  obstetric  forceps  tbe  following  rules 
must  be  observed : 

Use  of  Forceps.  —  (a)  An  accurate  aseptic  surgical  tecbnic,  includ- 
ing a  careful  cleansing  of  tbe  vulva  and  of  tbe  vaginal  introitus  witb  soap  and 
water,  followed  by  an  antiseptic  solution.  A  vaginal  doucbe  is  not  ordinarily 
required.  Tbe  forceps  must  be  tborougbly  sterilized  by  boiling,  and  tbe  bands 
of  tbe  operator,  after  tbe  usual  surgical  cleansing,  sbould  be  covered  witb  ster- 
ilized rubber  gloves. 

(h)  Successful  forceps  deliveries  demand  tbat  the  operator  sbould  bave  a 
knowledge  of  tbe  normal  and  abnormal  mecbanism  of  labor  ;  be 
must  also  recognize  tbe  exact  position  and  presentation  of  tbe   fetus. 

(c)  Mecbanical  skill  and  manual  dexterity  render  tbe  operator  more  effi- 
cient, but  tbe  most  skilful  use  of  tbe  ordinary  forceps  cannot  equal  tbe  precision 
of  an  axis  traction  forceps,   even  in  less  able  bands. 

(d)  A  practical  knowledge  of  pelvimetry  is  of  tbe  utmost  value. 
Pelvimetry  need  not,  after  all,  be  sucb  a  bugbear  as  it  is.  Only  five  or  six 
measurements  are  called  for,  and  tbese  are  always  easily  made  witb  a  tape 
measure  and  a  pair  of  calipers. 

(e)  Tbe  pbysician  must  make  it  a  fixed  rule  never  to  oper- 
ate through  an  undilated  cervix.  Disregard  of  this  rule,  together  witb 
a  faulty  tecbnic,  is  tbe  cause  of  many  of  tbe  disastrous  forceps  deliveries.  Tbe 
skilled  operator  appreciates  tbe  necessity  for  preliminary  dilatation  of  tbe  lower 
birth  canal,  and  when  the  natural  forces  fail,  be  is  familiar  with  the  usual 
excellent  methods  available  to  secure  such  dilatation.  These  are,  iu  order  of 
their  safety:  Eubber  bags,  such  as  the  Pomeroy  and  Voorhees,  or,  best  of 
all,  tbe  old  pear-shaped  bags  of  Champetier  de  Pabes ;  manual  meth- 
ods, such  as  those  of  Philander  A.  Harris  and  J.  Clifton  Edgar;  and  the 
graduated  metal  dilators  of  the  Hegar  type.  Xext  to  rigid  surgical 
cleanliness,  I  know  of  nothing  which  contributes  to  tbe  safety  of  forceps  deliv- 
eries so  greatly  as  tbe  securing  of  complete  dilatation  of  tbe  lower  birth  canal 
prior  to  the  application  of  the  forceps. 

In  cases  of    eclampsia,    where  immediate  delivery  seems  paramount  to 


RUI/ES    FOR    THE    USE    OF    FORCEPS.  483 

every  other  consideration,  the  medical  attendant  ninst  not  aUow  himself  to  yield 
to  the  natnral  temj^tation  to  grasp  a  foot  as  soon  as  it  can  be  felt,  and  drag  it 
through  the  undilated  cervix.  It  is  best  to  finish  the  dilatation  with  the  fingers 
while  the  patient  is  under  the  influence  of  the  chloroform.  There  are  two 
methods  of  finger  dilatation:  That  of  Harris  (Amer.  Jour.  Ohst., 
1894,  vol.  29,  p.  37),  by  stretching  the  cervix  through  the  introduction  of 
the  index  finger  and  the  thumb,  which  is  best  when  the  head  is  well  up;  and 
that  of  Edgar  ("  Obstetrics  ")  by  pulling  the  cervix  apart,  which  is  better 
when  the  head  is  low  down  on  the  cervix. 

The  obstetrician  will  do  well  to  make  use  of  high  forceps  operations  but 
rarely,  and  when  it  is  necessarj^,  to  use  an  axis-traction  instrument,  like  the  Tar- 
nier.  The  physician  who  uses  the  axis-traction  forceps  ought  to  have  a  clear 
mental  picture  of  the  direction  of  the  pelvic  axis  in  which  the  head  lies  at  any 
particular  moment ;  in  general,  he  first  pulls  down  towards  the  pelvic  floor,  then 
out  under  the  pubic  rami,  and  then  upwards.  The  alternative  is  to  wait  with 
patience  for  a  considerable  period,  so  as  to  give  the  cervix  a  long  time  to  dilate, 
and  the  head  time  to  accommodate  itself  by  moulding  its  form  to  the  pelvic 
canal.  Serious  harm  is  often  done  through  trying  to  assist  nature  overmuch 
by  working  the  cervix  back  over  the  head,  or  by  stretching  it  with  the  fingers. 
If  the  head  gets  wedged  at  any  point,  an  injudicious  use  of  the  forceps  will 
cause  a  slough,  which,  as  a  rule,  extends  through  into  the  bladder,  or  some- 
times into  the  rectum.  In  J.  W.  Williams'  clinic  at  the  Johns  Hopkins  Hos- 
pital the  custom  is  to  interfere  if  the  head  remains  wedged  in  one  place  for 
two  hours.  Good  evidence  that  the  frequent  use  of  the  forceps  is  really  an 
abuse  is  afforded  by  the  fact  that  so  many  excellent  practitioners,  especially 
in  country  districts,  manage  hundreds  of  cases  without  resorting  to  them  in  a 
single  instance.  When  it  is  really  necessary  to  use  forceps,  it  is  usually  possible 
to  avoid  injury  to  the  bladder  by  first  emptying  it  with  a  catheter ;  a  rubber 
one  is  best  for  this  purpose.  My  associate.  Dr.  G.  L.  Hunner,  was  once  called 
upon  to  take  a  glass  catheter  out  of  a  woman's  bladder ;  it  had  been  broken  off 
by  the  descent  of  the  head  in  a  pain  which  came  on  as  the  bladder  was  being 
emptied. 

It  is  also  important  that  the  physician  should  not  be  in  a  hurry  to  determine 
the  third  stage  of  labor.  He  should  give  the  placenta  at  least  an  hour  to  effect 
a  delivery,  and  previous  to  this  time  should  not  do  more  than  use  moderate 
force  in  pushing  down  from  above.  If  the  placenta  is  not  delivered  into  the 
vagina  by  this  time,  it  may  be  attached  to  the  uterus  as  the  sequel  of  an  en- 
dometritis. The  best  method  to  remove  it  then  is  by  introducing  the  gloved 
hand  into  the  uterus  and  using  the  edge  of  the  hand  as  though  it  were  a  knife, 
to  scoop  or  cut  the  placenta  off  from  the  uterine  wall.  The  cord  should  never 
be  pulled  upon  as  a  means  of  delivery. 

Protection  of  Perineum. — The  perineum  is  best  protected  by  re- 
straining the  head  from  passing  suddenly  and  precipitately 
through    the    outlet    under  the  force  of  a  violent  expulsive  pain.     Precipi- 


484  INJURIES    AND    AILMENTS    FOLLOWING    LABOR. 

tate  delivery  tliroiigh  tlie  vagiiia  and  the  vulvar  riiiij;  is  especially  likely  to  occur 
during  forceps  deliveries.  Kiii:)ture  of  the  perineum  can  best  be  prevented  by 
one  of  two  methods.  The  first  of  these  depends  upon  the  judicious  use  of 
chloroform ;  when  the  head  reaches  the  vulva  and  begins  to  distend  the  ring 
of  the  vaginal  outlet,  two  or  three  drops  of  the  anesthetic  with  the  first  pain, 
four  or  five  with  the  next,  and  so  on  until  the  head  escapes,  by  which  time  the 
patient  is  completely  anesthetized.  The  other  method  is  by  resistance  of  rapid 
dilatation  of  the  outlet  and  expulsion  of  the  head.  This  is  accomplished  by 
making  pressure  upward  and  inward,  holding  the  head  back  and  so,  in  part, 
preventing  the  powerful  propulsive  force  of  the  uterus  above  the  body.  In 
making  such  pressure,  a  gauze  pad  should  be  placed  on  the  perineum.  Pre- 
cipitate delivery  through  the  vagina  and  the  vulvar  ring  is  especially  liable  to 
occur  during  forceps  deliveries.  The  head  must  never  be  extracted  from  the 
vulva  by  one  effort  of  traction;  it  should  be  brought  down  slowly  and  delib- 
erately, as  far  as  possible  after  nature's  method,  either  by  allowing  it.  to  return 
between  the  pains  and  come  down  a  little  further  next  time,  or  by  removing  the 
forceps  and  letting  nature  finish  her  work  unassisted.  Hasty  obstetric  work  is 
a  source  of  much  danger  to  parturient  women,  just  as  it  has  ever  been  since 
men  discovered  how  to  assist  nature  in  this  respect.  Obstetricians  do  not  lay 
stress  upon  shoulder  tears. 

Immediate  Repair  of  the  Perineum. — If  the  perineum  is  deeply  torn  it  is 
wisest  to  sew  it  up  at  once.  It  is  the  practice  at  the  Johns  Hopkins  Hospital 
to  close  the  perineal  tear  after  the  birth  of  the  child  and  before  the  delivery 
of  the  placenta.  This  is  a  good  plan,  because  it  keeps  the  physician  actively 
engaged,  it  saves  time,  and  it  tends  to  greater  deliberation  in  dealing  with  the 
placenta.  In  order  to  repair  the  perineum,  the  patient  is  brought  to  the  edge 
of  the  bed,  after  which  the  wound  is  exposed  with  retractors,  and  then  closed 
with  silkworm-gut  sutures,  extending,  when  necessary,  up  each  vaginal  sulcus 
and  on  the  perineal  surface  (see  Figs.  115  and  116).  If  the  injury  goes 
through  into  the  bowel,  the  sutures  on  the  bowel  surface  must  be  passed  with 
special  care  in  order  to  secure  an  accurate  approximation  (see  Fig.  118). 
The  sutures  in  the  perineal  wound  should  not  be  tied  tight,  in  order  to  allow 
for  swelling  of  the  tissues.  Tight  sutures  are  apt  to  cut  through  into  the 
wound  itself.  Each  suture  should  be  passed  about  one-third  of  an  inch  from 
the  margin  of  the  wound ;  for  doing  this  I  use  a  large  curved  needle,  held  in 
a  strong  needle  holder,  armed  with  a  silkworm-gut  suture.  This  is  passed 
from  one  side  well  down  to  the  bottom  of  the  wound  and  then  up  and  out  at 
a  corresponding  point  on  the  opposite  side  of  the  tear  (see  Figs.  117  and 
118).  Two  or  three  of  these  sutures  are  sufficient  to  close  a  large  wound; 
it  is  a  mistake  to  put  in  a  number  of  sutures,  as  in  the  secondary  operation. 
It  does  no  harm  to  allow  for  a  little  drainage  between  the  sutures.  The 
sphincter  ends  are  best  united  by  a  suture  of  silkworm-gut,  which  transfixes 
the  muscle  and  passes  up  through  the  vagina.  The  remainder  of  the  perineal 
and  vaginal  wound  is  closed  by  a  series  of  interrupted  silkworm-gut  sutures. 


Fig.  115. — A  Partial  Tear  of  the  Perineum 
Extending  tip  Both  Sulci  and  Out  onto 
THE  Skin  Surface.  Two  sutures  passed  as 
shown  in  Fig.  115  serve  to  unite  the  torn  sur- 
faces. 


Fig.  116. — ^The  Sutures  Tied  and  the  Torn 
Surfaces  United. 


Fig.  117. — A  Deeper  Tear  of  the  Perineum 
Extending  Farthest  up  the  Left  Sulcus. 
The  surfaces  are  best  united  by  passing  .silk- 
worm-gut sutures  in  the  order  indicated,  and 
then  tying  them  snugly  together. 


Fig.  118. — A  Complete  Tear  of  the  Perineum 
Involving  the  Sphincter  Muscle.  Sutures 
should  b'e  passed  in  the  order  indicated.  Su- 
ture 4  transfixes  both  ends  of  the  sphincter 
and  serves  to  unite  them. 

485 


486 


IXJUEIES    AXD    AILME:XTS    FOLLOWING    LABOE. 


Repair  of  the  Cervix. — If  a  persistent  hemorrhage  occurs  in  the  presence  of 
a  well-contracted  uterus,  a  torn  cervix  should  be  suspected.  Its  existence 
can  he  demonstrated  by  bringing  the  patient  to  the  side  of  the  bed  and  retract- 
ing the  perineum,  at  the  same  time  catching  the  anterior  and  posterior  lips  of 
the  cervix  with  forceps  and  pulling  them  together.  A  bright  stream  of  blood 
is  sometimes  visible  between  the  lips  of  the  tear.  Repair  is  effected  by  passing 
t\vo  or  three  chromicized  catgut  sutures  with  a  stout  curved  needle  and  tying 
them  at  once. 

Precautions  against  Infection. — The  obstetrician  must  give  minute  atten- 
tion to   personal   cleanliness.      It   would   be   well   if   it   were    a   rule    for   all 

obstetricians  to  wear  thin  rubber  gloves,  and  to  make 
as  few  examinations  as  possible  during  the  course  of 
a  labor.  For  some  eighteen  years  it  has  been  my 
own  habit  to  wear  a  sterilized  suit  of  clothes  when 
attending  an  obstetric  case ;  if  this  is  too  much  to 
ask  of  the  general  practitioner,  he  might  at  least 
wear  a  sterilized  gown,  and  this  precaution,  together 
with  the  use  of  rubber  gloves,  and  the  surgical  clean- 
liness of  the  field  of  operation  would  relieve  him 
from  much  of  the  responsibility  which  must  always 
arise  in  connection  with  puerperal  infection  (see 
Fig.  119).  The  man  who  attends  obstetrical  cases 
ought  to  be  extremely  careful  about  coming  in  con- 
tact with  infectious  material  between  times.  For 
example,  he  should  never  examine  a  puerperal  infec- 
tion unless  protected  by  rubber  gloves,  and  in  driv- 
ing he  should  wear  gloves  which  can  be  washed 
and  boiled.  The  use  of  an  obstetric  cushion,  espe- 
cially among  the  poorer  class  of  patients,  is  valu- 
able in  the  conduct  of  labor,  as  it  always  leaves 
the  bed  clean  and  minimizes  the  amount  of  wash- 
ing to  be  done  afterwards.  The  cushion  ought  to 
be  covered  with  a  sterile  sheet,  and  as  the  amnion 
escapes,  it  can  be  dried  up  with  a  sterile  cloth  or 
absorbent  cotton.  If  the  cushion  becomes  infected, 
it  can  be  sterilized  by  boiling  or  by  soaking  in  a 
strong  antiseptic  solution  (bichloride  of  mercury, 
1:1000). 

TJse  of  the  Catheter.  —  If  it  is  necessary  to  cathe- 
terize  the  l)ladder  after  labor,  the  greatest  care  must 
1:0  exercised  to  have  a  clean  well-l)oiled  catheter 
fXo.  3),  to  cleanse  the  orifice  thoroughly  with  clean 
warm  boric  acid  solution  before  introducing  it;  and  then  to  insert  it  with 
the  greatest  caution  under  direct  inspection,   taking  pains   to   avoid  trauma. 


Fig.  119. —  The  Phtsiciax 
Dressed  IX  A  Sterile 
gow^v  with  examixixg 
Hand  Protected  by 
A  Sterilized  Rubber 
Glove  Ready  to  Attexd 

AND   EXAIIIXE   A   PaTIEXT 

IX  Labor.  Instead  of  a 
sterile  gown  a  sterilized 
linen  coat  may  be  worn. 
The  gown  gives  more  per- 
fect protection  to  the  pa- 
tient. 


CI-IOICE    OF    A    NURSE.  487 

The  nurse  or  the  physician  who  handles  the  catheter  ought   never    to    touch 
the    end    which    enters    the    bladder. 

Choice  of  a  Nurse. — ^The  nurse  is  a  potent  factor  in  the  weal  or  woe  of  the 
obstetric  patient.  Careless  midwives,  who  go  from  place  to  place,  indifferent  to 
all  considerations  but  the  fee  which  they  expect  to  receive,  often  carry  with 
them  the  seeds  of  infection,  and  their  progress  might  easily  be  traced  by  the 
funerals  which  follow  in  their  train.  In  this  country  we  stand  greatly  in  need 
of  a  well-trained  corps  of  midwives,  regulated  by  proper  laws ;  such  a  body  of 
women,  in  fact,  as  is  found  at  present  only  in  Germany.  The  physician  ought, 
at  least,  to  know  about  the  cases  a  nurse  has  recently  attended.  He  should  be 
sure  that  she  has  no  infectious  disease,  no  ozena,  nor  any  sore  about  her  person ; 
he  should  assure  himself  that  she  is  not  meddlesome  nor  anxious  to  give  douches, 
and  that  she  is  fully  instructed  in  the  details  of  the  correct  antepartum  toilet 
of  her  patient,  as  well  as  in  the  surgical  care  of  the  genitalia  and  of  the  breasts. 


CHAPTEE    XX. 

FIBROID  TUMORS. 

Definition,  p.  488.  Structure,  p.  488.  Classification,  p.  489.  Frequency,  p.  493.  Etiology,  p. 
494.  Life  history,  p.  494.  Degeneration,  p.  495.  Complications,  p.  496.  Symptoms :  Hem- 
orrhage, p.  497;  pain,  p.  498:  leucorrhea,  p.  498;  anemia,  p.  498.  Diagnosis,  p.  498.  Effect 
upon  neighboring  organs,  p.  503.  Effect  upon  distant  organs,  p.  504.  Treatment:  Elec- 
tricity, p.  507;  ergot  and  hydrastis,  p.  508;  stypticin,  p.  508;  thyroid  extract,  p.  508;  gela- 
tin, p.  508;  hot  douches,  p.  508;  paclang  for  hemorrhage,  p.  509;  intra-uterine  treatment,  p. 
509;  curettage,  p.  510;  general  considerations,  p.  510.     Fibroid  tumors  and  pregnancy,  p.  512. 

DEFINITION. 

Fibroid  tumor,  myoma,  or  fibromyoma  of  the  uterus  is  a  nodular  growth, 
springing  from  some  portion  of  the  uterus,  usually,  but  not  always,  above  the 
cervix,  and  varying  in  size  from  a  microscopic  node  to  a  mass  or  masses  filling 
the  pelvic  and  abdominal  cavities ;  the  largest  fibroid  on  record  is  one  removed 
at  autopsy  by  William  Hunter,  which  weighed  one  hundred  and  forty  poimds. 

STRUCTURE. 

Fibroid  tumors  are  generally  rounded  in  shape  with  a  smooth  exterior; 
they  are  single  or  multiple  (as  many  as  a  hundred  and  fifty  have  been  found  in 
one  uterus,  see  Bland  Sutton,  Brit.  Med.  Jour.,  1901,  vol.  1)  and  of  a  firm  con- 
sistency, though  a  predominance  of  muscular  tissue  in  their  structure,  or  the 
presence  of  degenerative  changes,  may  render  them  softer.  They  are  made  up 
of  tissues  similar  to  those  composing  the  myometrium,  namely,  unstriped  mus- 
cle and  connective-tissue  fibres.  On  section  the  tissues  are  seen  to  be  arranged 
in  a  disorderly  interlacement  of  muscular  and  connective  fibres,  which  in  the 
larger  masses  are  grouped  in  more  or  less  definite  whorls,  somewhat  resembling 
knots  in  a  piece  of  wood.  Between  the  groups  of  fibres  run  arteries,  veins, 
and  lymph  channels,  derived  from  the  normal  vessels  of  the  uterus,  which  at 
first  ramify  beneath  the  capsule  of  the  tumor  and  then  plunge  directly  into 
its  interior.  The  individual  tumors  are  encapsulated  in  the  uterus,  in  such  a 
manner  that  they  can  be  shelled  out  without  tearing  the  walls.  They  are 
classed  as  "  benign  tumors  "  because  they  do  not  penetrate  and  ramify  through- 
out the  surrounding  tissues,  nor  cause  destruction  by  metastases.  These  tumors, 
as  a  rule,  are  poorly  nourished,  because  they  derive  their  blood  supply  from 
the  surrounding  constricted  uterine  tissue,  but  occasionally  they  are  supplied 
by  large  vessels  formed  in  the  adhesions  between  them  and  surrounding  organs. 
488 


CLASSIFICATIOlSr. 


489 


CLASSIFICATION. 

Fibroid  tumors  may  be  classified  according  to  their  component  parts,  tbose 
containing  an  excess  of  muscular  tissue  being  called  myomata,  those  in 
which  connective  tissue  predominates,  fibromata  or  fibroids.  There 
is  still  another  group,  called  adenomyomata,  characterized  by  presence  of 
glands  similar  to  those  found  in  the  uterine  mucosa.  These  tumors  are  fre- 
quently diffuse  and  may  or  may  not  be  definitely  encapsulated.  Fibroid 
tumors   are  further  classified  according  to  their   situation  in  the  uterus,   as 


Fig    120 Illustrates  How  the  Location  of  a  Myoma  May  Determine  the  Form  which  the 

Myoma  Assumes.  The  upper  left  hand  figure  shows  three  typical  points  of  origin.  The  upper 
right  hand  figure  shows  a  myoma  developing  from  a  focus  in  the  posterior  wall.  The  lower  right 
hand  figure  shows  one  developing  from  a  focus  in  the  anterior  wall.  The  lower  left  hand  figure 
shows  one  developing  from  a  focus  in  the  fundus. 

follows:  (1)  Subserous,  including  (a)  intraligamentous  tumors  and 
(h)  tumors  of  the  cervix;  (2)  interstitial;  and  (3)  submucous. 
They  are  also  classified  by  their  number  and  size,  for  instance,  a    multiple 


490 


riBKOID    TUMOKS. 


an    intraligamentoiis    tu- 
These  tumors  have  the  greater 


fibroid,  a  large  interstitial  fibroid  of  the  posterior  uterine 
wall,  a  small  fibroid  of  the  anterior  wall,  and  a  small  subserous 
fibroid    springing    from    the    fundus    uteri. 

Subperitoneal  Fibroids. — All  fibroid  tumors  originate  in  the  uterine  muscle, 
therefore  they  are  interstitial  in  the  beginning  (see  Fig.  120),  but  if 
the  tumor  develops  in  the  outer  wall  of  the  uterus  and  grows  upward  under 
the  peritoneum  it  is  called  a    subperitoneal    fibroid    (see  Eig.  121).     In 

such  growths  the  greater  part  of  the 


periphery  is  outside  the  uterine  wall 
and  they  have  no  considerable  amount 
of  covering  of  uterine  tissue.  Their 
size  is  large  or  small  relatively  and, 
as  a  rule,  the  greater  the  size  of  the 
tumor  the  more  is  it  separated  from 
the  uterus.  If,  instead  of  developing 
under  the  serosa,  the  tumor  separates 
the  folds  of  the  broad  ligament,  it  is 
called 
m  o  r . 

part  of  their  circumference  outside 
of  the  uterus  and  are  not  covered  by 
uterine  tissue.  Xoble  ("  Gynecology 
and  Abdominal  Surgery,"  Kelly  and 
Xoble,  1907,  vol.  1,  p.  669)  states 
that  he  found  this  variety  of  fibroid 
tumor  in  three  and  a  half  per  cent 
of  two  thousand  two  hundred  and 
seventy-four  cases  of  fibroids  exam- 
ined by  him.  Tumors  originating  in 
the  lower  posterior  segment  of  the 
uterus  and  growing  first  into  the  cer- 
vix and  then  into  the  posterior  pelvis 
possess  the  same  characteristics,  as 
well  as  those  rare  growths  which  begin  in  the  cervix  itself  and  develop  away 
from  the  uterus.  The  cervix,  it  is  true,  has  no  covering  of  peritoneum,  but  as 
the  tumor  increases  in  size  and  rises  in  the  pelvis  it  pushes  the  peritoneum 
before  it,  and  therefore  this  class  of  tumors  may  be  included  among  the  sub- 
serous. In  all  subperitoneal  fibroids  the  shape  of  the  uterine  cavity  is  little 
if  at  all  altered. 

Interstitial  Fibroids. —  (Intramural  or  intraparietal.) — These  tumors  are 
situated  in  the  wall  of  the  uterus  and  surrounded  by  a  covering  of  uterine 
musculature.  They  may  or  may  not  alter  the  external  contour  of  the  uterus, 
but  the  uterine  cavity  is  almost  always  lengthened,  broadened,  and  often  ren- 
dered  asymmetrical  by  them.      The  fundus  of  the  uterus   in  the  case   shown 


Fig.  121. — Diagram  showing  Pedunculate  Sub 

PERITONEAL,  AND   INTERSTITIAL  TyPES  OF  MyO 
MATA. 


DEVELOPMENT    OP    SUBMUCOUS    FIBEOIDS. 


491 


in  Figure  122  was  lifted  as  high  as  the  umbilicus  and  the  canal  propor- 
tionately lengthened.  They  sometimes  develop  into  the  uterine  cavity  and 
are  covered  by  mucosa  with  little  if  any  of  the  uterine  musculature  (see 
Fig.  123). 

Submucous  Fibroids. — Of  all  three  varieties  of  fibroid  tumors,  the  sub- 
mucous occasion  the  greatest  changes  in  the  shape  and  dimensions  of  the 
uterine  cavity.  In  a  large  tumor,  starting  in  the  lower  part  of  the  uterus, 
the  distortion  of  the  uterine  canal  may  be  extreme.  The  pressure  exerted  by 
the  tumor  on  the  nervous  mechanism  of  the  uterus  excites  reflex  uterine  con- 


FiG.   122. — An  Interstitial  Myoma  Ghowixc  in  .srcn  a  ^Manner  as  to  Distort  the  Cervical  Canal 
AND  Enormously  Lengthen  the  Canal  of  the  Uterus. 

tractions,  which  by  their  expulsive  ppwer  cause  the  tumor  first  to  become 
pedunculate,  after  Avhich  the  pedicle  elongates  until  the  internal  os  is  dilated, 
and,  in  favorable  cases,  the  tumor  is  delivered.  More  often,  however, 
necrosis  of  the  tumor  sets  in  before  delivery  is  accomplished  and  we  have  a 
sloughing    fibroid.      A    pedunculate    submucous    fibroid,    if    small,    is 


492 


FIBKOLD    TUJtIOKS. 


called  a   fibroid  polyp   and  must  be  distinguislied  from  a   mucous  polyp, 
which    is   one   of   the   manifestations    of   glandular    endometritis.      The 

German  authorities  maintain  that 
the  mucous  membrane  of  the  cor- 
pus uteri  shows  evidence  of  gland- 
ular and  interstitial  endometritis 
in  all  forms  of  fibroids  and  es- 
pecially the  submucous  variety. 
CuUen,  however  ("  Cancer  of  the 
Uterus,"  1900,  p.  535),  denies 
this  opinion,  stating  that  the  mu- 
cous membrane  in  fibroid  tumors 
is  generally  normal ;  but,  he  adds, 
"  it  must  be  borne  in  mind  that 
polypi  may  also  be  present " 
(see  Fig.  124)  ;  he  further  notes 
that  there  are  various  degTces  of 
atrophy,  and  of  glandular  hyper- 
trophy, and  that  mild  degTees  of 
endometritis  are  sometimes  pres- 
ent. In  many  fibroids  the  endo- 
metrium shows  signs  of  hyper- 
trophic  changes,  while  in  others 

123. DiAGR.OI    SHOWIXG    SUBMUCOUS   AND   InTER-        •,•,,]• 

STiTiAL  Types  of  Myomata.  It  IS    atropUlC. 


Fig. 


Fig.  124. — Uterus  Amputated  at  the  Txterxal  Os  and  Laid  Opex,  showixg  Ixterstitial  Myomata 
IX  the  Body  and  at  the  Fundus  a  Polyp. 


SITUATION    AND    FEEQUENCY. 


493 


SITUATION. 

ribroid  tumors  always  develop  in  tlie  substance  of  tbe  uterine 
wall,    originating  much  oftener  in  the  body  than  in  the  neck  and  more  com- 


FiG.  125. — Showing  a  Mtoma  in  the  Anterior 
Wall  of  the  Uterus  and  Its  Effect  upon 
THE  Bladder. 


Fig. 


126. — Showing  Large  Myoma  in 
Posterior  Wall. 


monly   in  the   posterior  than  in  the   anterior   or  lateral  wall    (see  Figs.   125 
and  126). 

FREQUENCY. 

Fibroid  tumors  are  the  most  common  of  uterine  growths.  The  relative 
number  of  women  with  fibroids  was  stated  by  S.  H.  Bayle  {Diet,  en  60  tomes, 
Paris,  1813,  vol.  7,  p.  73),  as  long  ago  as  1813,  to  be  twenty  per  cent  of  all 
who  were  over  thirty-five  years  of  age,  and  for  many  years  his  statistics  were 
generally  accepted.  Others,  however,  have  arrived  at  different  results;  J.  M. 
Klob,  for  instance  ("  Path.  Anat.  Female  Sexual  Organs,"  Eng.  transL,  1868, 
p.  177),  asserts  that  forty  per  cent  of  the  uteri  of  women  dying  after  their 
fiftieth  year  contain  fibroids ;  the  exact  frequency  of  these  growths,  therefore, 
has  yet  to  be  determined,  but  one  fact  definitely  established  is  that  they 
occur  most  often  during  the  period  of  sexual  maturity,  that  is,  between  the 
ages  of  thirty  and  fifty,  being  rare  before  twenty  and  after  fifty-five  years 
of  age.  Gusserow  (Hart  and  Barbour,  "  Manual  of  Gynecology,"  1904,  p. 
424)  found  that  out  of  nine  hundred  and  nineteen  cases  of  fibroids  there  were 
only  fifteen  under  tw^enty  years  of  age  and  only  seventeen  over  sixty ;  the 
highest  percentage,  thirty-eight  and  eight-tenths,  was  between  the  ages  of  thirty 
and  forty,  while  the  next  highest,  thirty-six  and  seven-tenths,  was  between  forty 
and  fifty.  It  w^as  formerly  supposed  that  fibroids  were  almost  invariably  pres- 
ent in  the  negro  race  after  the  thirtieth  year  (T.  G.  Thomas,  "  Diseases  of 
Women,"  1872,  p.  485),  but  more  recent  observers  are  of  a  different  opinion; 
J.  W.  Williams,  who  represents  the  extreme  reaction  from  this  opinion,  found 
them  only  two  per  cent  more  frequent  in  negroes  than  in  whites  in  three  hun- 
dred and  seventy-five  cases  analyzed  by  him  at  the  Johns  Hopkins  Hospital. 


494  FIBROID    TUMORS. 

It  is  not  yet  determined  whether  filjroids  are  more  common  among  single 
women  than  married;  Bayle  {loc.  cit.)  and  otlier  authorities  thought  that  they 
were,  while  Gusserow,  Dupuytren,  West,  and  others  held  that  they  were  not. 

ETIOLOGY. 

The  etiology  of  fibroid  tumors  is  still  shrouded  in  mystery,  although  the 
problem  has  been  studied  assiduously  by  many  investigators  during  the  last 
fifty  years,  amongst  whom  are  Klebs,  Kleinwachter,  Gebhard,  Connheim, 
Virchow,  and  Gottschalk ;  many  hypotheses  have  been  advanced,  but,  so  far, 
none  has  been  proved.  An  ingenious  theory,  recently  advanced,  is  that  of 
A.  Claisse  (These  de  Paris,  1900),  wdiich  attributes  them  to  an  infection 
of  the  uterine  mucosa,  giving  rise  to  subacute  inflammation  causing 
proliferation  of  the  round  cells  which  are  transformed  into  fibrous  tissue. 
Heredity  has  been  supposed  to  play  a  part  in  the  causation  of  fibroids, 
Hofmeier,  Yeit,  Kleinwachter,  and  others  considering  it  a  predisposing  cause ; 
a  fact  substantiated  by  the  appearance  of  fibroid  tumors  in  different  mem- 
bers of  the  same  family.  Sexual  irritation,  such  as  masturbation, 
or  abnormal  sexual  practices,  has  even  been  assigned  as  a  cause  of 
myoma  by  Yeit  ("Handbuch  der  Gynakologie,"  1897,  voL  2,  p.  452)  and 
other  writers,  but  while  the  chronic  congestion  arising  from  undue  irritation 
of  the  genital  organs  may  assist  the  growth  of  a  fibroid,  it  is  difiicult  to  see 
how  it  could  originate  one.  It  is  probable  that  many  fibroids  are  of  con- 
genital origin;  a  plausible  theory  is  that  which  tries  to  harmonize  fibroids 
with  other  tumors  by  assigning  them  to  a  fetal  misplacement  of  the 
tissues,  according  to  Cohnheim's  theory.  Age  plays  the  most  important 
part  in  bringing  about  the  growth  of  the  tumors,  for  they  almost  always  become 
manifest  late  in  the  child-bearing  period.  As  regards  race,  they  are  un- 
doubtedly most  common  in  negroes.  Family  is  undoubtedly  a  factor  in 
their  causation,  as  two,  or  even  three  sisters  have  repeatedly  been  operated 
upon  for  them. 

LIFE    HISTORY. 

The  development  of  a  myoma  may  be  very  slow.  I  have  known  one  case 
which  was  under  medical  observation  for  twenty-five  years  before  operation 
and  two  years  afterwards  ("  Operative  Gynecology,"  2d  edition,  1907,  vol.  2, 
p.  347),  where  a  large  interstitial  tumor,  with  a  uterine  cavity  measuring 
eight  or  nine  inches,  became  larger,  subperitoneal,  and  pedunculate,  so  that 
at  operation  it  was  found  attached  to  a  small  uterus  by  a  pedicle  one  centi- 
metre long  by  three  broad ;  it  weighed  fifty-nine  pounds.  The  direction  of  the 
growth  is  a  matter  of  importance,  for  upon  the  course  taken  its  subsequent 
fate  often  depends.  For  instance,  if  it  growls  so  as  to  become  subserous  it 
may  become  pedunculate  and  in  course  of  time  become  separated  entirely  from 
the  uterus,  receiving  its  nourishment  through  adhesions  to  surrounding  struc- 


LIFE    HISTORY    AND    DEGENERATION.  495 

tures;  such  cases,  however,  are  rare.  If,  on  the  other  hand,  the  tumor  grows 
towards  the  uterine  cavity  and  becomes  of  tlie  submucous  variety  it  is  often 
extruded  through  the  external  os.  In  either  case  the  blood  supply  to  the  tumor 
is  interfered  with  and  there  is  danger  of  necrosis  and  degenerative  changes. 
If  the  tumor  remains  in  the  substance  of  the  uterus  as  an  interstitial  fibroid, 
its  nourishment  is  established  on  a  surer  footing.  It  is  possible  for  all  tumors, 
and  especially  small  ones,  to  remain  in  a  quiescent  state  for  an  indefinite 
period.  Bland  Sutton  ("  Tumors  Innocent  and  Malignant,"  4th  edition,  1906, 
p.  187)  calls  attention  to  the  latent,  or  seedling  fibroid,  in  regard  to 
which  he  says :  "  If  a  number  of  uteri  from  women  between  the  twenty-fifth 
and  fiftieth  years  be  examined  by  the  simple  means  of  sectioning  with  a  knife, 
in  a  large  proportion-  of  these  uteri  a  number  of  small  rounded  fibroids, 
resembling  knots  in  wood,  will  appear,  their  whiteness  being  in  strong  contrast 
to  the  surrounding  muscle  tissue.  These  discrete  bodies,  in  many  instances 
no  larger  than  mustard  seeds,  are  in  histologic  structure  identical  with  the 
fully  grown  tumors."  Under  these  circumstances,  we  can  never  be  sure  when 
fibroids  are  removed  at  an  operation  that  all  of  them  have  been  taken  out, 
and  therefore  a  patient  cannot  be  assured  that  other  fibroids  will  not  grow. 
In  some  cases  the  tumors  increase  very  rapidly  in  size.  Their  rapidity  of 
growth  is  usually  in  inverse  proportion  to  the  age  of  the  patient.  The  younger 
the  patient  the  more  rapid  the  rate  of  growth.  Soft  tumors  grow  faster  than 
hard  ones;  they  increase  rapidly  during  pregnancy  and  diminish  markedly 
after  delivery,  while  after  the  menopause  much  increase  is  uncommon.  Just 
before  each  menstrual  period  they  become  larger  and  decrease  in  size  when 
the  flow  has  ceased ;  in  many  instances  they  lessen  after  the  menopause,  but 
not  invariably.  All  these  facts  must  be  kept  in  mind  when  a  patient  is  exam- 
ined at  intervals  to  determine  the  relative  bulk  of  a  tumor. 

DEGENERATION. 

There  are  certain  structural  alterations  in  fibroids,  the  causes 
of  which  we  do  not  know,  except  that  sometimes  they  can  be  explained  by  the 
presence  of  an  arteriosclerosis  and  a  diminished  blood  supply.  An  increased 
formation  of  fibrous  and  hyaline  tissue  occurs  in  practically  all  myomata,  and 
when  the  process  is  extensive,  necrosis  takes  place  at  the  centre  of  the  growth, 
resulting  in  the  formation  of  a  cyst  cavity  with  walls  of  irregular  outline. 
Hyaline  degeneration  w^as  noted  in  three  and  one-tenth  per  cent  of  two 
thousand  two  hundred  and  seventy-four  cases  of  fibroids  collected  from  litera- 
ture by  IsToble  {loc.  cit.,  p.  669).  Some  degree  of  hyaline  change  is  exceed- 
ingly common.  Fibroids  may  become  progressively  indurated,  especially  after 
the  menopau,se ;  small  hard  tumors  being  found  at  autopsies  on  old  women 
when  their  presence  has  not  been  suspected  during  life. 

Calcification  (the  so-called  "uterine  stones")  is  rather  a  rare  trans- 
formation; which  l^oble  found  in  one  and  seven-tenths  of  his  cases.      It  is 


495  PlBKOtD    TUMORS. 

effected  by  deposits  of  phosphate  and  carbonate  of  lime  formed  near  the  centre 
or  the  periphery  of  the  tumor  which  make  either  a  bony  framework  (not,  how- 
ever, true  bone)  or  a  shell;  the  tumor  is  rarely  entirely  solidified,  but  it  nuist 
be  remembered  that  small  areas  of  calcification  are  extremely  common. 

Softening  of  a  fibroid  tnmor  may  be  due  to  several  causes.  Col- 
loid or  myxomatous  degeneration  is  characterized  by  the  effusion  of 
mucous  material  between  the  muscle  bundles  and  distinguished  from  edema 
by  the  proliferation  of  round  cells  in  the  interstitial  tissue.  Noble  {Joe.  cit.) 
found  myxomatous  degeneration  in  three  and  four-tenths  per  cent  of  the  cases 
he  collected  from  literature.  A  proliferation  of  connective  tissue  becoming 
colloid  during  pregnancy  has  been  noted  by  Doleris  (Arch,  de  tocol.,  janv. 
et  juin,  1883,  pp.  1,  363).  The  diminution  in  size  after  delivery  has  been 
attributed  to  fatty  degeneration,  and  Gusserow  ("Die  ISTeubildungen 
des  Uterus,"  1886)  has  called  attention  to  the  fact  that  fatty  degeneration 
of  a  fibroid  has  been  demonstrated  microscopically  in  only  three  cases,  those 
of  Freund,  A.  Martin,  and  Brunnings,  where  there  had  not  been  resulting 
diminution  in  the  size  of  the  tumor  as  well.  There  is  one  form  of  fibroid, 
called  lipomyomata,  in  which  a  portion  of  the  tumor  is  composed  of  fatty 
tissue;  such  a  case  has  been  described  by  E.  Peterson  (Amer.  Jour.  Ohst.,  1904, 
vol.  49,  p.  393).  Edema  is  often  observed  in  fibroids  and  may  be  considered 
as  an  early  stage  of  necrosis ;  it  is  most  frequently  seen  in  the  subperitoneal 
tumors.  Fibro-cystic  tumors  result  from  the  breaking  down  and  lique- 
faction of  areas  of  degeneration  in  myomata,  and  when  this  degeneration  is 
extensive  on  account  of  the  fusion  of  the  different  foci,  a  large  cyst  with 
irregularly  shaped  walls  may  be  formed. 

Amyloid  degeneration  in  a  fibroid  polyp  has  been  reported  in  a  single 
case  by  C.  B.  Stratz  (Zeiischr.  f.  Geh.  u.  Gyn.,  1889,  vol.  17,  part  2,  p.  80). 
Suppuration  arises  from  infection  of  the  tumor  with  bacteria  derived  from 
the  intestinal  canal,  the  genital  tract,  or  the  blood ;  prolonged  pressure  of  a 
tumor  on  the  bowel,  or  an  adherent  vermiform  appendix  may  permit  easy 
penetration  of  the  micro-organisms.  Infection,  especially  in  the  case  of 
a  submucous  fibroid,  may  also  proceed  from  instrumental  or  digital  invasion 
of  the  uterine  cavity  for  exploration  or  curettage.  Gangrene  may  result 
from  degeneration,  or  from  torsion  of  the  pedicle,  and  micro-organisms  may 
or  may  not  play  a  part  in  the  necrobiotic  process. 

Sarcomatous  degeneration  occurred  in  two  per  cent  of  the  cases 
collected  by  Noble  {loc.  cit.)  ;  and  Winter  {Zeitschr.  f.  Geh.  u.  Gyn.,  1906, 
vol.  57,  p.  19)  found  sarcoma  in  four  and  one-third  per  cent  of  two  hundred 
and  fifty-three  tumors  in  which  sections  were  taken  from  different  parts  of 
the  growth. 

COMPLICATIONS. 

Carcinoma  occurs  as  an  associated  lesion  in  fibroid  tumors,  not  as  a 
degeneration,  except  in  a  few  cases  of  adenomyoma  where  cancer  has  been 


COMPLICATIONS    AND    SYMPTOMS.  497 

described  as  springing  direct  from  the  glands  within  the  tumor.  In  a  study 
of  four  thousand  eight  hundred  and  eighty  consecutive  cases  of  fibroid  tumor, 
ISToble  (loc.  cit.,  p.  670)  found  cancer  in  two  and  eight-tenths  per  cent;  in  his 
personal  experience  with  three  hundred  and  thirty-seven  fibroids,  cancer  of  the 
fundus  was  present  in  two  and  six-tenths  per  cent  and  cancer  of  the  cervix  in 
one  and  four-tenths,  and  as  women  without  fibroid  tumors  have  cervical  can- 
cer ten  times  as  often  as  cancer  of  the  fundus,  he  concluded  that  there  must 
be  a  causal  relation  between  fibroma  and  cancer  of  the  body  of  the  uterus 
(adeno-carcinoma  of  the  endometrium). 

Disease  of  the  tubes  and  ovaries  due  to  infection  is  not  an 
infrequent  complication  of  fibroid  tumors.  C.  Daniel  studied  this  subject  in 
Pozzi's  clinic  {Rev.  de  gyn.  et  de  chir.  ahd.,  1903,  vol.  7,  pp.  25,  196)  and 
found  that  in  most  cases  where  the  complication  occurred,  the  ovaries,  or  the 
ovaries  and  tubes  together,  were  diseased;  the  tubes  alone  were  rarely  affected. 
He  collected  one  hundred  and  thirty-nine  cases  from  literature  in  addition  to 
those  under  his  own  observation  and  found  that  the  tubes  alone  were  affected 
thirty-two  times ;  the  ovaries  alone  seventy-nine  times ;  and  the  tubes  and 
ovaries  together  twenty-eight  times.  In  seventy  cases  observed  in  Pozzi's  clinic 
the  most  common  complications  of  this  kind  were  catarrhal  salpingitis, 
purulent  salpingitis,  hematosalpinx,  and  cystic  degeneration  of 
the  ovaries.  In  ISToble' s  cases  (loc.  cit.,  p.  668)  complications  in  the  uterine 
appendages  or  in  the  pelvis  existed  in  thirty-seven  per  cent.  In  Pozzi's  clinic, 
lesions  of  the  tubes  and  ovaries  occurred  in  fifty-nine  per  cent  of  the  myoma 
cases.  It  must  not  be  forgotten,  however,  that  these  large  percentages  were 
found  among  women  who  entered  the  hospital  for  operation  for  fibroid  tumors, 
and  it  is  hardly  fair  to  assume  that  all  fibroids  are  subject  to  complications  to 
the  same  extent;  in  fact,  most  of  the  statistics  founded  on  cases  collected 
from  the  literature  of  the  subject  are  open  to  the  objection  that  they  deal 
with  an  abnormally  large  proportion  of  fibroids  which  are  giving  rise  to  active 
symptoms. 

SYMPTOMS. 

The  symptoms  of  fibroid  tumors  are:  Hemorrhage,  with  its  resulting 
anemia,  pain,  leucorrhea,  constipation,  frequency  of  urination, 
dysuria,  and  retention  of  urine,  the  four  latter  symptoms  being  the 
result  of  pressure  on  rectum,  ureters,  bladder,  or  urethra. 

Hemorrhage. — The  bleeding  caused  by  fibroid  tumors  may  be  in  the  form 
of  menorrhagia  or  metrorrhagia,  but  most  frequently  the  former.  It 
is  a  symptom  most  common  in  the  submucous  variety  of  tumor,  less  frequent 
in  the  interstitial  form,  and  rarely  seen  in  the  subserous  growths.  As,  how- 
ever, most  fibroid  tumors  are  multiple,  it  is  not  always  easy  to  say  which  form 
predominates  in  a  given  case  of  hemorrhage.  The  submucous  tumors  cause 
bleeding  by  enlarging  the  surface  of  the  endometrium,  the  total  number  of 
square  inches  being  increased  many  times  in  the  case  of  large  growths.  Dia- 
33 


498  FIBROID    TUMOES. 

pedesis  of  red  Idood  corjinscles  tlirougli  the  walls  of  the  capillaries  of  the  endo- 
metrium takes  j)lace  iu  proportion  to  the  extent  of  surface  involved ;  hut 
venous  congestion,  occasioned  by  the  pressure  of  the  tumur  on  die  thin-walled 
veins,  is  supposed  to  be  the  principal  causal  factor  in  the  mechanism  of  hemor- 
rhage in  fibroid  tumors,  the  arteries  with  their  thick  elastic  walls  being  better 
able  to  withstand  pressure.  The  increase  of  the  menstrual  flow  may  be  but 
slight,  or  it  may  amount  to  excessive  hemorrhage  requiring  active  treatment ; 
the  size  of  the  tumor  bears  no  relation  w^hatever  to  the  extent  of  the  flow,  small 
growths  sometimes  causing  the  greatest  hemorrhage.  It  is  a  curious  fact  that 
with  some  women  the  flow  is  greater  when  they  are  lying  down  than  when 
they  are  up  and  about,  a  fact  exactly  opposite  to  the  usual  condition  of  things 
in  menorrhagia. 

Anemia  is  such  a  frequent  result  of  hemorrhage  that  the  indications  of  it, 
as  a  pale  face,  colorless  lips,  eyes  of  pearly  white,  flabby  muscles,  a  bounding 
but  compressible  pulse  with  increased  rapidity  on  the  smallest  excitement, 
breathlessness,  and  a  feeling  of  languor  are  well  known  to  everyone.  The 
red  blood  corpuscles  may  fall  to  one-fifth  or  less  of  their  normal  number 
(5,000,000)  and  the  hemoglobin  to  thirty  per  cent;  hemic  murmurs  are  usu- 
ally present. 

Pain. — Pain  may  or  may  not  be  present  in  fibroid  tumors,  and  when  it 
does  occur,  is  variable  in  amount;  it  assumes  several  forms:  as  a  dull 
resistant  pain  in  one  or  both  groins  or  across  the  abdomen,  a 
be  a  ring- down  pain,  or  a  backache,  and  these  varieties  may  exist  sepa- 
rately or  conjointly.  It  may  be  referred  to  the  thighs  or  the  legs  in  conse- 
quence of  the  pressure  of  the  tumor  on  the  sacral  plexus  of  nerves.  Pressure 
on  a  ureter  may  cause  pain,  but  the  rectum  and  bladder  are  generally  tolerant 
of  pressure  so  far  as  pain  is  concerned,  their  disturbance  when  pressed  upon 
showing  itself  in  derangement  of  function.  Dysmenorrhea  occurs  in  about 
twenty  per  cent  of  the  cases  of  fibroid  tumors  (see  Chap.  IV,  p.  HI),  the 
cramp-like  pain  being  often  severe.  It  must  be  remembered,  however,  that  an 
uncomplicated  fibroid  rarely  gives  rise  to  much  pain,  and  therefore  the  presence 
of  pain,  especially  if  severe,  indicates  a  pelvic  inflammatory  complication. 
Pain,  as  a  rule,  arises  from  the  pressure  of  a  growing  tumor ;  expulsive  pains 
are  found  when  the  tumor  becomes  pedunculate  and  can  be  extruded  either  in 
part  or  wholly  at  the  external  orifice. 

Leucorrhea. — A  vaginal  discharge  is  rare  in  fibroids  except  in  the  sub- 
mucous form,  when,  if  the  tumor  is  necrotic,  the  discharge  is  malodorous.  A 
profuse  watery  discharge  associated  with  fibroids  should  always  excite  sus- 
picion of  cancer. 

DIAGNOSIS. 

The  diagTLOsis  of  large  fibroid  timiors  is  a  comparatively  easy  matter,  but 
the  detection  of  small  ones  is  often  difficult,  for  the  svmptoms  are  not  of  much 
assistance,  except  that    painful    and    protracted    menstruation    with  a 


DIAGNOSIS    OF    SUBPEEITONEAI,    EIBEOIDS.  499 

history  of  sterility  or  of  early  iniscarriugcs  are  suggestive  of  myoma. 
The  chief  reliance  in  diagnosis  must  be  npon  bimanual  palpation  and 
the  passage  of  the  uterine  sound.  The  first  point  in  diagnosis  is 
always  to  determine  the  relation  of  the  tumor  to  the  body  of  the  uterus. 

Subperitoneal  Fibroids. — If  the  tumor  is  a  single  mass,  bimanual  palpation 
will  show  whether  it  is  connected  with  the  uterus.  To  determine  this  point,  the 
tip  of  the  forefinger  must  be  placed  in  the  vagina  on  the  cervix  and  the  other 
hand  on  the  abdomen;  if,  on  moving  the  tumor  with  the  external  hand,  the 
cervix  moves  at  the  same  tim.e,  the  fact  of  connection  is  established.  The 
growth  should  always  be  outlined  as  accurately  as  possible,  but  the  laxity  and 
the  thinness  of  the  abdominal  walls  greatly  influence  paljDation;  it  is  easily 
and  thoroughly  done  when  the  abdominal  walls  are  thin  and  lax,  but  when 
the  patient  is  inclined  to  corpulence,  it  may  be  extremely  difficult.  In  cases 
where  the  tumors  are  small,  the  ovaries  can  be  located  and  mapped  out;  an 
attempt  to  do  this  should  be  made  in  every  case.  If  the  tumor  is  peduncu- 
late, it  must  be  distinguished  from  an  ovarian  cyst,  which  is  easy,  if  fluctuation 
can  be  detected ;  this  point  is  determined  by  making  firm  pressure  against  the 
tumor  with  the  finger  in  the  vagina  and  tapping  with  the  fingers  of  the  hand 
on  the  abdomen  when,  if  fluctuation  is  present,  the  taps  will  be  transmitted  as 
waves  to  the  finger  in  the  vagina.  If  the  contents  of  the  cyst  are  thick  and 
semi-solid,  as  in  the  case  of  dermoid  cysts,  the  fluid  waves  will  be  absent.  Some 
ovarian  cysts,  it  is  true,  are  as  hard  as  fibroids ;  but,  as  a  rule,  fibroids  are 
solid,  there  is  more  than  one  nodule,  and  the  nodules  are  of  stony  hardness. 
If  the  tumor,  or  tumors,  are  large  enough  to  distend  the  abdomen,  the  uterus 
is  drawn  up  in  the  pelvis,  but  this  does  not  take  place  in  the  case  of  an 
ovarian  tumor. 

A  pedunculate  cystic  myoma  may  be  distinguished  from  an  ovarian 
cyst  tumor  by  grasping  the  cervix  uteri  with  forceps  and  pulling  it  well  down. 
The  tumor  is  then  grasped  through  the  abdomen  on  its  under  surface  and 
pushed  up  toward  the  diaphragm.  If,  the  moment  the  tumor  is  displaced,  the 
instrument  in  the  cervix  is  pulled  upon  also,  the  tumor  is  uterine.  It  takes  a 
little  time  and  displacement  before  the  cervix  and  the  tenaculum  forceps  are 
pulled  upon  in  the  event  of  the  tumor  being  ovarian.  A  careful  rectal  palpation 
reveals  the  pedicle  of  a  fibroid  attached  to  the  uterus,  while  it  shows  that  an 
ovarian  cyst  is  lateral  and  replaces  the  normal  ovary,  which  cannot  be  found. 

Whenever  the  sound  is  passed,  it  must  be  with  due  regard  to  the 
probable  direction  of  the  uterine  canal,  as  determined  by  bimanual  palpation, 
and  strict  antiseptic  precautions  must  be  observed;  the  date  of  the  last  men- 
struation must  always  be  ascertained  so  that  pregnancy  may  not  be  unwittingly 
interrupted.  In  the  case  of  subserous  fibroids  the  uterine  canal  will  not  be 
found  lengthened. 

Pregnancy. — A  fibroid  tumor  is  not  always  easily  distinguished  from 
pregnancy,  and  it  is  still  more  difficult  to  recognize  a  pregnancy  complicated 
with  fibroids.     The  diagnosis  must  be  made  by  the  following  signs : 


500  FIBKOID    TUMOES. 

(1)  lu  prognaiiej  cessation  of  menstruatiou,  liitlicrto  regular;  in  fibroids 
a  tendency  to  increase  of  flow. 

(2)  Equable  enlargement  of  the  nterus,  most  common  in  pregnancy. 

(3)  Softening  of  tlie  uterine  walls  to  a  marked  degree,  while  the  organ 
itself  is  not  larger  than  a  three  months'  pregnancy;  a  fibroid  rarely  becomes 
cystic  until  larger  than  this. 

(4)  In  pregTiancy  softening  of  the  lower  segment  of  the  uterus  (Hegar's 
sign,  see  Chap.  VI,  p.  151)  ;  never  present  in  fibroids. 

(5)  In  pregTiancy  discoloration  of  the  vaginal  vault;  rarely  present  in 
fibroids. 

(6)  Increased  softening  of  the  cervix  in  pregnane}'. 

(7)  jSTausea  and  breast  changes  present  in  pregnancy;  extremely  rare  in 
fibroids. 

(8)  When  the  tumor  is  very  large  the  fetal  heart  sounds  can  sometimes  be 
heard,  which  will  serve  at  once  to  distinguish  between  the  two. 

(9)  If  pregnancy  is  present  examination  a  month  later  will  show  enlarge- 
ment corresponding  to  the  period  of  time  which  has  elapsed. 

In  the  case  of  a  fibroid  associated  with  pregnancy,  mistakes  have  been  made 
by  the  best  ]3hysicians,  but  this  is  usually  because  they  have  been  taken  off 
their  guard,  and  finding  an  evident  large  myomatous  uterus  have  neglected  to 
inquire  as  to  the  menstrual  function  and  other  changes  suggesting  pregnancy. 

Pelvic  inflammatory  exudate  may  complicate  fibroid  tumors,  but 
is  seldom  mistaken  for  them.  In  such  inflammation  the  mass  is  brawny  and 
fills  in  the  chinks  of  the  pelvis,  and  there  is  a  history  of  fever,  even  if  the 
thermometer  does  not  reveal  its  presence  at  the  time  of  the  examination. 

Cancer  of  the  pelvis,  originating  in  the  ovaries  or  the  uterus,  may  be 
mistaken  for  fibroid  tumor,  but  it  should  be  differentiated  by  the  fixity  of  the 
infiltration  and  the  lack  of  definite  outline  in  the  tumor. 

•  x\scites  is  occasionally  associated  with  large  tumors,  and  its  presence  is 
shown  by  the  fact  that  a  change  of  position  in  the  patient  causes  a  change  in 
the  position  of  the  fluid,  wliich  may  be  mapped  out  by  its  percussion  flatness. 

Intraligamentous  Fibroid. — This  form  of  fibroid  is  situated  at  one  side  of 
the  uterus,  its  situation  being  shown  by  the  sound,  even  if  it  cannot  be  pal- 
pated; it  is  low^  down  in  the  pelvis  and  can  often  be  felt  projecting  into  the 
vagina.     Its  mobility  is  limited  on  account  of  its  attachments  and  its  situation. 

Interstitial  Fibroid. — In  these  tumors  the  uterine  enlargement  may  be  sym- 
metrical or  asj-mmetrical ;  in  the  latter  case  the  diagnosis  is  easy,  in  the  former 
pregnancy  must  first  be  excluded  (see  Tig.  127).  To  do  this  the  history  must 
be  carefully  taken,  especially  as  regards  amenorrhea  ;  the  elastic  feeling  of 
the  pregnant  uterus  must  be  sought  for  as  well  as  softening  of  the  cervix,  and 
bulging  of  the  anterior  segment.  If  there  is  the  slightest  suspicion  of  preg- 
nancy, the  sound  must  not  be  passed.  In  interstitial  fibroids,  hemorrhage 
is    a    prominent   symptom,    and   the   uterine   canal   will    usually   be 


DIAGNOSIS    OF    SUBMUCOUS    H'lJJKOlDS. 


501 


found   lengthened.     If  the  abdominal  walls  are  tense,  or  the  conditions  for 
examination  are  not  wholly  satisfactory,  examination  under  ether  is  advisable. 


w^l^^ 


Fig.  127. — Globular  Myomatous  Uterus  presenting  Form  of  Pregnant  Uterus  at  Term,  with 
Adaptation  of  the  Lower  Part  of  its  Form  to  that  of  the  Pelvic  Cavity.  The  lower  part 
of  the  tumor  is  subperitoneal,  and  the  cervix  is  displaced  up  to  the  level  of  the  pelvic  brim.  Two 
peritoneal  adhesions  are  shown  above  the  cervical  opening.  Seen  from  behind.  Hystero-myo- 
mectomy.     Recovery.     Path.  No.  325.     ^  natural  size. 


Submucous  Fibroids. — In  almost  all  cases  of  submucous  tumor,  there  is  a 
history  of  hemorrhage,  and  bimanual  palpation  shows  an  enlargement  of  the 
uterus,  even  in  small  growths.  The  diagnosis  is  established  by  the  sound,  and, 
if  necessary,  by  digital  exploration  of  the  uterine  cavity.  The  sound  shows 
enlargement  and  distention  of  the  uterine  cavity  ;  but,  if  the 
tumor  is  situated  at  the  fundus,  nothing  but  digital  exploration  will  decide 
whether  it  is  sessile  or  pedunculate,  although  something  may  often  be  ascer- 
tained by  the  tactile  perception  transmitted  through  the  exploring  sound.  If 
a  digital  exploration  of  the  uterine  cavity  is  to  be  made,  the  cervix  may  some- 
times be  dilated  by  a  series  of  Goodell-Ellinger  dilators,  three  sizes,  followed 
by  large  Simon  dilators.  In  cases  of  hard  resistant  cervices,  however,  it  is  best 
to  incise  the  anterior  wall  of  the  cervix  ("  Operative  Gynecology,"  2d  edit., 
vol.  1,  p.  596),  repairing  the  cervix  by  suture  after  the  exploration  is  finished. 

A  sessile  submucous  fibroid  of  the  fundus  may  be  mistaken  for  adenoma 
or  adeno-carcinoma  ;  the  only  means  of  distinguishing  between  the  two  is 
the  removal  of  a  piece  for  microscopic  examination. 

A  pedunculate  tumor  presenting  at  the  external  os  may  be  mistaken  for 


502 


FIBKOID    TUMOKS. 


inversion,  or,  if  it  is  slongiiing,  for  cancer  of  tlie  cervix  (see  Fig.  128). 
It  is  distinguished  from  cancer  by  ascertaining  that  the  sound  may  be  swept 
entirely  around  it  and  that  the  cervix  itself  is  free  from  disease ;  and  from  in- 


Uterine  Cavity 


Uterine  Cavity 


Fig.  128. — Large  Pedunculate  Submucous  Myoma  Protruding  into  Vagina.     The  center  of  the 

tumor  is  necrotic. 

version  by  observing,  through  bimanual  recto-abdominal  touch  under  ether, 
whether  the  fundus  uteri  is  in  its  normal  situation;  moreover,  an  inverted 
uterus  is  usually,  thougli  not  invariably,  sensitive  to  touch. 


EFFJiCT    UPOJSr    WEIGHBOKING    OKGAJSTS. 


503 


EFFECT    UPON    NEIGHBORING    ORGANS. 

The  uterus  is  more  or  less  limited  in  its  movements  bj  its  attachments  to 
the  vagina  and  the  broad  ligaments,  and  if  a  fibroid  tumor  develops  in  its 
substance  it  may  displace  the  bladder,  or  press  the  rectum,  the  urethra,  or  the 
ureters  against  the  bony  framework  of  the  pelvis.  Such  pressure,  hoAvever, 
rarely  causes  retention  of  urine,  because  the  bladder  adapts  itself  readily  to 
misplacement  and  the  urethra  is  protected  by  the  pubic  arch  (see  Fig.  129). 


Fig.  129. 


-Large  Myoma  Developing  in  the  Anterior  Wall  of  the  Uterus  and  Causing  Pressure 
Symptoms  in  Both  Rectum  and  Bladder. 


Constipation  from  interference  with  the  function  of  the  rectum  by  pressure 
from  a  fibroid  is  of  common  occurrence,  and  injury  of  the  ureters  and  kidneys 
from  pressure  on  the  ureters  is  much  more  frequent  than  was  formerly  sup- 
posed. J.  H.  M.  Knox  (Amer.  Jour.  Obst.,  1900,  voL  42,  pp.  348,  496)  has 
reported  a  series  of  cases  of  compression  of  the  ureters  observed  during 
operations  on  fibroids  at  the  Johns  Hopkins  Hospital.  Of  all  the  different 
forms  of  fibroids,  intraligamentous  growths  and  tumors  developing  from  the 
cervix  are  most  apt  to  compress  the  ureters  as  well  as  to  displace  them  upward ; 
they  also  cause  the  greatest  amount  of  interference  with  the  enlarge- 
ment  of  the   uterus   during  pregnancy   and  with   delivery. 


504  FIBROID    TUMORS. 

Fibroid  tumors  are  also  a  cause  of  abortion.  Lefour  (These  d'agreg.  cle 
Paris,  1880)  noted  thirty-nine  abortions,  or  twelve  and  seven-tentbs  per  cent, 
out  of  three  hundred  and  seven  cases  of  pregnancy;  the  mother  dying  in  four- 
teen; and  ISTauss  {These  de  Halle,  1882)  found  that  abortion  took  place  in 
forty-seven  cases,  or  fifteen  per  cent,  out  of  two  hundred  and  forty-one  cases. 

Delivery  is  obstructed  by  tumors  situated  in  the  lower  uterine  seg- 
ment ;  when  they  develop  in  the  substance  of  the  uterus,  they  generally  interfere 
with  involution,  and  may  be  the  cause  of  post-partum  hemorrhage  and  sub- 
involution. 

The  presence  of  a  fibroid  is  not  an  absolute  bar  to  pregnancy,  nevertheless 
it  is  a  frequent  cause  of  sterility.  Olshausen  ("  Myom  und  Schwanger- 
schaft,"  J.  Veit,  "  Handbuch  der  Gynakologie,"  vol.  2,  p.  765)  collected  statis- 
tics on  the  subject  from  nine  different  observers,  including  Scanzoni,  Schroder, 
and  Hofmeier,  which  showed  that  out  of  one  thousand  seven  hundred  and 
thirty-one  married  women  with  fibroid  tumors,  five  hundred  and  twenty,  or 
thirty  per  cent,  were  sterile.  He  considered  this  figure  too  high,  however,  be- 
cause many  women  with  fibroids  only  consult  a  physician  on  account  of  sterility, 
and  those  who  become  pregnant  do  not  often  consult  a  physician  at  all. 

EFFECTS  ON  DISTANT  ORGANS  AND  ON  THE  SYSTEM  IN  GENERAL. 

Anemia. — One  of  the  most  common  results  of  fibroid  tumors  is  anemia, 
induced  by  prolonged  and  repeated  hemorrhages ;  the  hemoglobin  may  be  re- 
duced as  low  as  thirty  per  cent,  or  even  less,  and  the  red  cells  to  one  million. 
The  affection  is  a  serious  one  and  is  sometimes  difiicult  to  correct,  even  after 
the  loss  of  blood  has  been  stopped.  Acute  hemorrhage  rarely  proves  fatal 
in  fibroid  tumors,  but  the  continued  loss  of  blood  produces  a  condition  of  low- 
ered vitality  and  a  disposition  to  thrombosis,  embolism,  or  phlebitis, 
which,  in  extreme  cases,  contra-indicates  operation  for  removal  of  the  gro^vth. 
Some  authorities  state  that  the  hemoglobin  should  be  at  least  fifty  per  cent 
before  a  hysterectomy  is  undertaken.  I  have  operated  upon  twenty-three 
patients  who  were  completely  exsanguinated,  and  with  a  hemoglobin  count 
below  thirty  and  even  below  twenty  per  cent,  and  I  have  lost  but  two  cases 
from  this  cause.  It  occasionally  happens  that  several  years  elapse  before  a 
profoundly  anemic  patient  regains  good  health  after  the  cause  of  the  loss  of 
blood  has  been  removed. 

Heart  Disease. — The  frequency  of  cardiac  palpitation  in  fibroid  tumors  has 
been  noted  by  W.  L.  Burrage  (Amer.  Jour.  Obst.,  189i,  voL  29,  p.  320)  ;  it 
appears  to  be  quite  independent  of  actual  heart  lesions,  there  being  no  evidence 
of  enlargement  or  of  adventitious  murmurs,  and  it  is  possibly  the  effect  of 
anemia,  in  which  case  we  should  expect  to  find  hemic  murmurs.  The  exact 
relation  between  fibroids  and  heart  disease,  however,  is  not  knoT\Ti.  Certain 
degenerative  changes  in  the  heart  and  blood  vessels,  such  as  brown  atrophy, 
fatty    degeneration    and    fattj"    infiltration    of    the    heart    muscle. 


EFFECT    UPON    DISTANT    ORGANS    AND    ON    THE    SYSTEM    IN    GENERAL.  505 

and  clironic  endocarditis,  as  well  as  sclerosis  of  the  arteries,  have 
heen  noted  by  different  students  of  this  point,  notably  Hofmeier,  Fenwick, 
Strassman,  Lehmann,  Boldt,  Pellanda,  Winter,  and  Fleck,  cited  by  ISToble  (loc. 
cit.,  p.  671).  Winter  found  the  heart  itself  perfectly  normal  in  sixty  per  cent 
out  of  two  hundred  and  sixty-six  cases  examined  with  reference  to  this  point  by 
a  sjDCcialist  in  internal  medicine,  valvular  disease  was  present  in  but  one  per 
cent,  and  dilatation  and  hypertrophy  in  six  per  cent.  It  is  difficult  to  see  how 
lesions  of  the  heart  can  be  caused  by  fibroid  tumors  of  the  uterus,  and  I  think 
Ave  may  agree  with  Winter  that,  in  the  present  state  of  our  knowledge,  almost 
all  the  cardiac  symptoms  associated  with  fibroid  tumors  should  be  attributed  to 
consequent  derangement  of  the  nervous  system  or  to  grave  anemia.  It  is  well 
to  remember,  however,  that  heart  disease  may  accompany  fibroids,  though  not 
in  a  causal  relation. 

Immediate  Danger  to  Life. — Fibroid  tumors  may  under  certain  conditions 
be  a  direct  menace  to  life.  C.  Pellanda  ("  La  mort  par  fibromyomes  uterins," 
Lyon,  1905)  states  that  out  of  one  hundred  and  seventy-six  fatal  cases  of  fibro- 
myomata  studied  by  him,  death  was  due  to  hemorrhage  in  six  and  four- 
tenths  per  cent.  Acute  abdominal  emergencies  of  different  kinds,  arising 
from  infection  of  the  tumor,  are  by  no  means  unknown.  Rupture  of 
the  uterus,  due  to  obstruction  of  labor  by  fibroids,  has  been  known  to  occur. 
As  a  rule,  however,  fibroid  tumors  endanger  life  indirectly  by  their  de- 
generation and  their  complications  which  interfere  with  the  function  of 
distant  organs  and  by  their  effect  upon  the  general  health.  They  can  also 
destroy  life  by  pressure  on  the  ureters,  by  cardio-vascular  changes, 
and  by  septic  infection,  as  well  as  by  embolism.  A  serious  complica- 
tion is  a  bad   pelvic   inflammatory   disease. 

TREATMENT. 

It  is  now  generally  agreed  that  the  only  curative  treatment  for  fibroid 
tumors  is  surgical  in  its  nature;  therefore,  all  other  forms  of  treatment  may 
be  classed  as  palliative,  though  they  are  none  the  less  important  on  that 
account.  Fibroid  tumors,  as  I  have  said,  increase  in  size  just  before  menstrua- 
tion when  pelvic  congestion  is  greatest,  and  diminish  in  size  after  it  is  over,, 
when  the  congestion  is  past.  Anything,  therefore,  which  lessens  pelvic  con- 
gestion and  consequent  engorgement  decreases  the  size  of  the  tumor.  This  fact 
is  the  basis  of  the  treatment  of  abdominal  tumors  by  irregular  practitioners, 
who  give  the  patient  powerful  cathartic  pills  which  cause  violent  purging.  In 
a  case  of  this  sort  under  my  observation,  a  woman  with  a  large  abdominal  tumor 
had  been  taking  such  pills  until  she  had  an  exfoliative  enteritis ;  the  tumor  was 
much  reduced  in  size  while  she  was  taking  the  pills,  and  she  was  told  by  the 
quack  w^ho  prescribed  them  that  the  tissue  passed  per  anum  consisted  of  portions 
of  the  growth  cast  off  in  that  manner,  an  opinion  which  satisfied  the  poor  soul, 
though  she  was  growing  weaker  daily. 


506  FIBKOID    TUMOKS. 

The  determining  factors  in  the  treatment  of  fibroids  are : 

(1)  The  situation  and  size  of  the  tumor. 

(2)  Complicating  conditions  such  as  carcinoma,  pelvic  inflammatory  disease 
and  ovarian  tumors. 

(3)  Hemorrhages. 

(4)  Pain. 

(5)  Rapidity  of  gTOwth. 

(6)  Symptoms  of  degeneration. 

(7)  Age. 

(8)  Pressure  signs. 

(9)  Undue  mental  distress  on  account  of  the  tumor. 

There  is  in  these  days  a  tendency  to  exaggerate  the  seriousness  of  the  com- 
plications and  degenerations  of  fibroids,  and  those  who  promulgate  these  teach- 
ings are  wont  to  recommend  the  removal  of  all  fibroids. 

Rest  and  Care. —  It  must  always  be  understood  in  the  treatment  of  fibroids 
that  a  fibroid  tumor  without  complications  and  not  giving  rise  to  symptoms 
does  not  require  any  treatment  at  all.  In  cases  where  the  only  symptom  is  an 
excessive  menstrual  flow,  rest  in  bed  for  several  successive  days  at  each 
menstrual  period,  systematically  carried  out,  will  be  found  to  control  the  loss 
sufficiently  to  postpone  serious  anemia  indefinitely. 

Every  woman  with  a  fibroid  tumor  should  be  seen  and  examined  by  a  physi- 
cian about  every  six  months  so  that  changes  in  its  situation,  density,  and  size 
may  be  noted,  as  well  as  the  presence  and  effects  of  hemorrhage  and  pain; 
under  such  conditions  most  fibroids  are  really  benign  tumors.  ISTot  by  any 
means  every  fibroid  requires  operative  treatment,  though  what  we  now  know 
of  the  associated  maligTiant  changes  in  the  uterus  has  greatly  increased  the 
indications  for  operation  and  brought  them  nearer  to  the  indications  for  it  in 
the  case  of  ovarian  tumors. 

A  subperitoneal  tumor  of  small  size,  if  it  causes  no  symptoms,  requires  no 
treatment,  although  it  should  be  carefully  watched.  If  it  increases  in  size  and 
becomes  wedged  in  the  pelvis,  or  if  it  causes  retroversion  by  traction  on  the 
uterus,  it  should  be  pushed  up  into  the  abdomen  by  bimanual  manipulation, 
with  the  patient  in  the  knee-breast  posture,  traction  on  the  cervix  being  made 
at  the  same  time  with  a  tenaculum.  By  this  means  the  uterus  is  replaced  and 
pelvic  congestion,  a  condition  favoring  enlargement  of  the  growth,  is  lessened. 
In  some  cases  of  this  kind  it  is  well  to  fit  a  pessary  to  keep  the  uterus  in 
place  and  to  prevent  the  return  of  the  fibroid  to  the  pelvis,  especially  if  the 
patient  is  near  the  menopause ;  it  must  be  understood,  however,  that  should 
evidences  of  degeneration,  tenderness,  or  softening  appear,  the  pessary  must 
be  removed. 

An  interstitial  or  a  submucous  fibroid  should  receive  the  same  treatment. 
In  the  event  of  hemorrhage  or  of  severe  pain  much  benefit  may  be  derived  from 
the    use   of   intra-uterine    sralvanism. 


TREATMENT    BY    ELECTKICITY.  507 

Electricity. — For  many  years  electricity  was  supposed  to  have  a  selective 
effect  on  the  tissues  composing  a  fibroid.  As  far  back  as  1869  Ciniselli  of 
Cremona  {Mem.  presents  a  la  soc.  de  cliir.  de  Paris,  1869)  published  the  results 
of  his  treatment  of  fibroids  by  the  electro-chemical  method,  in  which  the  gal- 
vanic current  was  passed  through  the  tumor  by  means  of  two  needles,  inserted 
into  it  through  the  vagina.  Cutter,  in  America,  Keith,  in  London,  and  Apos- 
toli,  in  Paris,  were  the  chief  advocates  of  the  electrical  treatment  in  the  last 
thirty  years  of  the  nineteenth  century.  Their  treatments  were  intra-uterine  and 
made  by  puncture.  Galvanism  was  used  as  high  as  two  hundred  milliamperes. 
There  is  no  positive  evidence  that  electricity  causes  diminution  in  the  size  of 
fibroid  tumors,  and  on  the  other  hand,  the  dangers  attending  the  puncture  treat- 
ment through  possible  injury  to  the  bladder,  the  intestine,  or  the  ureter,  by  the 
introduction  of  pathogenic  organisms,  have  been  manifest  to  all,  so  that  this 
form  of  electrical  treatment  has  been  abandoned.  The  intra-uterine  abdominal 
form,  however,  with  small  or  moderate  doses  (ten  to  fifty  milliamperes)  is  of 
great  value  in  controlling  hemorrhage,  relieving  pain,  and  improving  the  gen- 
eral nutrition.  A  platinum  electrode  two  inches  in  length  attached  to  a  hard- 
rubber  stem,  or  a  platinum  electrode  protected  by  a  sliding  rubber  sheath  is 
inserted  into  the  uterus  under  strict  antiseptic  precautions.  A  wire  gauze  pad, 
eight  inches  by  four,  covered  thickly  for  the  depth  of  an  inch  with  absorbent 
cotton,  is  soaked  in  hot  water,  soaped,  and  placed  on  the  abdomen ;  the  posi- 
tive pole  is  connected  with  the  uterine  electrode  and  the  negative  pole  with  the 
gauze  pad,  after  which,  with  the  aid  of  a  rheostat,  a  current  of  from  twenty 
to  fifty  milliamperes  is  gradually  turned  on.  The  treatment  should  last  from 
six  to  ten  minutes  and  be  repeated  every  third  day. 

The  positive  pole  has  a  drying  hemostatic  effect  locally  on  the  endometrium.. 
The  galvanic  current  improves  the  nutrition  of  the  tissues  of  the  body  and  thus 
promotes  good  health.  La  Torre  (Societd  lancisiana  degli  ospedale,  Rome, 
Dec.  9,  1889)  found  that  electrical  treatment  stopped  or  diminished  hemor- 
rhage in  seventy  to  ninety  per  cent  of  fibroid  tumors ;  relieved  or  diminished 
pain  in  fifty  to  sixty  per  cent;  and  improved  the  general  health  in  sixty  to 
eighty  per  cent.  Burrage  (Amer.  Jour.  Obst.,  1894,  vol.  29,  p.  320),  after 
treating  fifty-four  cases,  found  the  pain  relieved  in  sixty  per  cent ;  hemorrhages 
permanently  cured  in  thirty  per  cent;  and  the  general  health  permanently 
improved  in  eighty-four  per  cent. 

If  relatively  small  doses  of  galvanism  are  employed,  the  risk  of  causing 
stenosis  of  the  uterine  canal  is  obviated;  larger  current  strengths  are  painful, 
cause  vesicular  eruptions  on  the  skin  of  the  abdomen,  and  have  no  beneficial 
effect  on  the  tumor.  Galvanism,  given  with  a  vaginal  electrode,  is  sure  to  cause 
injury  of  the  mucous  membrane  of  the  vagina,  even  with  small  dosages.  If 
the  uterine  cavity  is  large  and  distorted,  it  is  impossible  to  reach  all  parts  of  it 
with  any  electrode,  no  matter  how  ingeniously  constructed ;  therefore,  in  such 
eases,  other  means  for  the  control  of  hemorrhage  must  be  employed.  This  treat- 
ment is  the  work  of  a  specialist. 


508  FIBROID    TUMORS. 

Ergot. — Hypodermic  injections  of  ergot  have  teen  employed  in  the  treat- 
ment of  fibroid  tumors  since  the  time  of  Hildebrandt,  who  first  used  the  drug 
in  1872  (Berl.  hl'in.  Wockenschr.,  18 Y2,  'No.  25).  From  the  known  effect  of 
ergot  in  causing  contractions  of  the  uterine  muscles,  it  was  supposed  that  the 
prolonged  use  of  it  could  diminish  the  size  of  fibroid  tumors,  but  years  of  trial 
and  much  discussion  have  failed  to  demonstrate  any  efficacy  in  this  respect.  As 
a  means  for  the  control  of  hemorrhage,  however,  ergot  is  of  distinct  value,  as 
well  as  the  fluid  extract  of  hydrastis  canadensis,  which  at  one  time  was 
supposed  to  cause  shrinkage  of  the  tumors  by  its  contractile  effect  on  the  blood 
vessels.  Ergot  may  be  given  in  the  form  of  the  fluid  extract  in  doses  of  fifteen 
to  twenty  drops  in  water  every  two  hours.  The  fluid  extract  of  hydrastis  is 
given  in  doses  of  twenty-five  drops,  two  or  three  times  a  day ;  or  the  two  drugs 
may  be  given  in  combination.  Hydrastis  is  more  apt  to  disturb  the  digestion 
than  ergot,  and  must,  therefore,  be  given  with  circumspection. 

Stypticin,  a  micro-crystalline,  yellow  powder,  soluble  in  water  and  having  an 
intensely  bitter  taste,  has  given  good  results  in  some  hands.  H.  J.  Boldt 
(Amer.  Med.,  1904,  vol.  60,  p.  93)  treated  thirty-five  cases  of  fibromyomata 
with  this  drug,  and  obtained  satisfactory  results  in  thirty-one  per  cent  of  them. 
Boldt  recommends  doses  of  two  and  a  half  to  five  grains  repeated  at  intervals 
of  two  or  three  hours.  Three  to  five  grains  in  a  ten  per  cent  solution,  injected 
subcutaneously  into  the  buttocks,  produces  a  quick  effect. 

Thyroid  extract,  in  doses  of  five  grains,  three  or  four  times  a  day,  has  given 
good  results  in  some  cases  of  myoma.  Great  caution  must  be  observed 
in  the  use  of  it,  however,  and  should  the  heart  action  show  the  slightest 
evidence  of  disturbance,  in  rapidity  of  action,  irregularity  of  the  pulse,  or 
cyanosis  of  the  face  or  lips,  it  must  be  discontinued  at  once.  It  is  best  to 
begin  with  a  dose  of  two  grains  and  increase  it  gradually  up  to  five  grains. 

Gelatin  has  proved  useful  in  the  control  of  hemorrhage  from  fibroids  in  some 
cases.  A  ten  per  cent  sterile  solution  has  been  put  upon  the  market  by  various 
manufacturers,  and  this  may  be  used  for  hypodermic  injections,  diluted  one 
half  with  hot  sterile  water,  one  hundred  to  five  hundred  cubic  centimetres  being 
injected  into  the  buttocks.  The  injection  of  gelatin  into  the  uterine  cavity  has 
been  described  on  page  187.  The  gelatin  is  most  useful  in  cases  where  the 
blood  coagulates  more  slowly  than  usual  (that  is  to  say  takes  more  than  three 
to  four  minutes).  Calcium  lactate  also  is  of  value  in  this  class  of  cases, 
given  in  doses  of  twenty  gTains,  three  or  four  times  a  day,  for  long  periods 
of  time. 

Prolonged  hot  vaginal  douches  are  of  great  benefit  in  controlling  hemorrhage 
in  many  cases.  If  one  is  to  be  given,  the  patient  should  be  in  her  night-dress, 
and  should  lie  on  her  back  with  the  buttocks  raised  higher  than  her  shoulders 
by  means  of  a  douche  pan  placed  under  them.  At  least  six  quarts  of  water 
should  be  used  at  a  temperature  of  110°  to  120°  E. ;  the  fountain  syringe  or 
douche  pan  is  hung  not  more  than  three  or  four  feet  above  the  patient  and  the 
usual  hard  vaginal  nozzle  employed.     After  the  douche,  the  patient  should  rest 


TREATMENT    FOR    HEMOEEHAGE.  509 

for  at  least  two  lioiirS;,  and  it  may  be  repeated  twice  or  even  three  times  in 
twenty-four  hours. 

A  large  ice-bag  placed  on  the  abdomen  sometimes  proves  useful  in  les- 
sening hemorrhage. 

In  severe  cases  the  patient  should  be  kept  absolutely  at  rest  in  bed ;  the  diet 
limited  to  solid  articles  of  food,  and  all  stimulants,  whether  spices,  hot  or  alco- 
holic beverages,  prohibited. 

Packing  for  Hemorrhage. — Many  of  the  mechanical  measures  for  check- 
ing hemorrhage  have  been  described  already  (see  Chap.  VII,  p.  186).  One 
of  the  best  of  these  is  packing  the  vagina  with  wool  or  cotton 
tampons  covered  with  vaselin.  The  patient  should  preferably  be  in 
the  knee-breast  posture,  or  that  of  Sims ;  a  large  quantity  of  vaselin  and 
tampons  of  small  size  should  be  used,  the  vagina  being  packed  as  tightly  as 
possible.  If  this  treatment  is  not  efficacious,  the  uterine  cavity  should 
be  packed  with  aseptic  gauze  covered  with  vaselin.  To  do  this 
the  cervix  must  be  dilated  by  means  of  Hanks  dilators  sufficiently  to  admit  a 
Burrage  uterine  speculum ;  the  end  of  a  long  piece  of  gauze,  one  inch  wide,  is 
carried  well  down  to  the  fundus  with  a  forked  packer,  and  the  cavity  packed 
from  the  fundus  down,  after  which  the  vagina  is  packed  with  vaselin  tampons. 
The  gauze  must  be  all  in  one  piece  and  the  end  should  project  from  the  external 
OS.  Some  gynecologists  soak  the  gauze  in  a  ten  per  cent  sterile  solution  of 
gelatin  instead  of  vaselin,  and  get  good  results.  E.  C.  Dudley  ("  Principles 
and  Practice  of  Gynecology,"  4th  edition,  p.  359)  cites  a  remarkable  case  in 
which  intra-uterine  sterile  gauze  packing  not  only,  controlled  hemorrhage,  but 
resulted  eventually  in  the  almost  total  disappearance  of  a  large  fibroid  tumor. 

It  is  not  proper  to  go  on  treating  a  woman  suffering  from  hemorrhage 
month  after  month,  and  the  lines  of  treatment  suggested  here  are  rather  for 
adoption  while  waiting  to  carry  the  patient  to  a  surgeon.  A  patient  who  needs 
packing  for  hemorrhage  is  clearly  a  surgical  case. 

Intra-uterine  Treatment. — It  must  always  be  remembered  that  in  the  in- 
vasion of  the  uterine  cavity  the  utmost  caution  is  necessary,  for  even  with  the 
strictest  aseptic  precautions,  sepsis  has  followed  the  simplest  intra-uterine  treat- 
ments. Kubinyi  (Centrbl.  f.  Gyn.,  1904,  voL  28,  p.  T75)  reports  the  case  of  a 
primiparaj,  forty-two  years  old,  who  had  a  multiple  fibroid  filling  the  lower 
abdomen  attended  by  menorrhagia ;  she  had  been  treated  by  an  intra-uterine 
injection  of  iodine  on  three  successive  days,  and  five  days  later  she  had  high 
temperature,  pain,  chills,  and  a  foul  vaginal  discharge.  At  the  end  of  a  week, 
as  she  still  appeared  septic,  the  abdomen  was  opened  and  supra-vaginal  hysterec- 
tomy performed,  when  it  was  found  that  there  was  a  necrotic  area  in  the  en- 
dometrium with  thromboses  of  the  vessels  extending  into  the  tumor. 

Pincus  ("  Atmokausis  und  Zestokausis,"  Wiesbaden,  1903)  points  out  the 
dangers  attending  treating  the  interior  of  the  uterus  in  the 
case  of  myomata  with  live  steam,  although  a  strenuous  advocate  of  it 
as  a  therapeutic  measure  in  many  other  pathological  conditions.     In  fibroid 


510  FIBROID    TUMORS. 

tumors  tlie  cauterization  is  so  little  under  control  tliat  it  may  affect  an  area  of 
unknown  size  in  the  uterine  inlerior  witli  necrosis,  so  that  its  use  is  not  to  be 
advised. 

Curettage,  which  is  so  valuable  in  relieving  uterine  hemorrhage  associated 
with  disease  of  the  endometrium,  is  of  much  more  limited  value  in  the  treat- 
ment of  myomata.  Moreover,  it  is  frequently  followed  by  sloughing  and 
resulting  infection  of  the  tumor.  It  may  be  definitely  stated,  therefore,  that 
curettage,  like  other  forms  of  intra-uterine  treatment,  should 
not   be   employed   for  myomata. 

General  Considerations. — The  treatment  of  a  pedunculate  sub- 
mucous nodule  is  exclusively  surgical.  It  is  not  good  treatment  to 
administer  ergot  to  a  patient  with  a  fibroid  of  submucous  evolution  in  the  ex- 
pectation that  the  uterine  contractions  will  cause  extrusion  of  the  tumor.  If 
the  tumor  does  not  occasion  excessive  hemorrhage,  the  patient  may  be  treated 
with  iron  and  constitutional  tonics  until  the  tumor  becomes  pedunculate  in  the 
natural  course  of  development.  If  the  hemorrhage  is  excessive,  and  the  methods 
already  described  are  of  no  avail,  the  uterine  cavity  may  be  packed  as  already 
described.  The  stimulation  has  been  known  to  cause  the  extrusion  of  the  tumor 
from  the  uterine  wall. 

If  the  tumor  is  pedunculate,  it  should  be  removed  under  strict  aseptic 
precautions.  The  growth  should  be  seized  with  four-toothed  volsella  forceps 
and  twisted  until  it  comes  away;  if  hemorrhage  follows,  it  can  usually  be  con- 
trolled by  swabbing  the  interior  of  the  uterus  with  pledgets  of  gauze  soaked  in 
equal  parts  of  the  tincture  of  iodine  and  pure  carbolic  acid,  taking  care  first  to 
protect  the  vagina  with  gauze.  Should  the  bleeding  be  excessive,  it  must  be 
controlled  by  irrigating  the  interior  of  the  uterus  wdth  scalding  water,  and  if 
this  fails,  by  packing  with  dry  gauze.  Wlien  the  pedicle  can  be  seen  or  felt, 
it  can  be  tied  with  catgiit  and  cut  off  distally  to  the  ties.  It  may  be  necessary 
to  use  the  uterine  scissors  to  separate  the  tumor  or  to  trim  out  bits  of  tissue 
by  the  twisting  process.  If  exploration  of  the  uterine  cavity  with  the  finger 
(see  p.  501)  reveals  the  presence  of  several  tumors  and  an  extensive  operation  is 
indicated,  the  case  should  be  referred  to  a  gj^necologist. 

If  the  tumor  is  sapping  the  patient's  strength  by  pain,  or  hemorrhage  with 
its  attendant  anemia,  a  radical  operation  should  be  advised ;  and  the  same 
advice  obtains  if  there  are  degenerative  changes  or  if  jDregiiancy  is  prevented. 
Due  regard  must  be  shown,  of  course,  to  the  most  favorable  time  for  operation 
as  regards  symptoms,  the  possibility  of  future  pregnancies,  and  the  condition  of 
the  general  health.  It  is  not  sufficient  to  make  a  diagnosis  of  fibroid  tumor, 
decide  upon  operation,  and  appoint  a  day  for  it;  no  radical  operation  should 
be  advised  until  the  physician  has  become  thoroughly  familiar  wdtli  all  the  cir- 
cumstances of  his  patient's  social  condition,  as  well  as  with  the  facts  concerning 
the  tumor  itself,  and  the  symptoms  it  excites. 

If  operation  is  decided  on,  the  patient  must  be  put  into  the  best  possible  con- 
dition for  what  may  prove  to  be  a  severe  tax  on  all  the  vital  resources  of  the  sys- 


GENEEAL    CONSIDERATIONS    IN    TREATMENT. 


511 


tem.  The  percentage  of  liemoglobin  and  iJie  number  of  the  red  Llood 
corpuscles  should  be  determined;  the  urine  should  be  examined; 
the  heart  and  lungs  auscultated  and  percussed  and  any  abnormali- 
ties noted;  the  skin  must  be  put  into  good  order  by  hot  baths; 
anemia  corrected  by  iron  and  arsenic;  and  heart  tonics  and 
diuretics  ordered,  if  indicated.  ISTo  radical  operation  should  be  per- 
formed if  there  is  an  advanced  nephritis,  or  a  persistent  gly- 
cosuria. A  pyelitis  may  be  helped  by  taking  the  pressure  off  the  ureter.  In 
bleeders  it  is  frequently  necessary  to  check  hemorrhage  by  artificial  means  dur- 
ing several  menstrual  periods,  at  the  same  time  administering  iron  and  ordering 
forced  feeding  until  the  patient  is  in  proper  condition  for  operation.  Some 
patients  are  in  such  an  impover- 
ished condition  that  it  is  of  the 
utmost  importance  to  save  every 
drop  of  blood,  and  time  spent  in 
preparation  for  operation  in  such 
cases  is  well  expended. 

The  relative  merits  of  a  myo- 
mectomy or  a  hysterectomy  can 
be  determined  only  by  the  surgeon 
at  the  time  of  operation.  It  seems 
hardly  worth  while  to  consider 
the  operations  of  ligature  of  the 


Fig.  131- 

AFTER 

Wall. 


130  and 
provided 


Fig.  130. — Showing  a  Globular  Myoma- 
tous Uterus  Delivered  through  an 
Abdominal  Incision.  The  hands  are 
employed  merely  in  showing  the  tumor. 

uterine  arteries  or  oophorectomy 
performed  to  cause  atrophy  of 
fibroid  tumors,  because  the  re- 
sults of  myomectomy  and  hys- 
terectomy in  competent  hands 
are  now  so  satisfactory,  and  if 
any  operation  is  performed,  it  is 
better  to  remove  the  tumor  alto- 
gether and  thus  obviate  the  risk 
of  subsequent  degeneration  and 
other  harmful  effects  (see  Figs. 
131).  Myomectomy  should  always  be  preferred  in  a  young  woman, 
there  are  no  complicating  conditions,  such  as  extreme  anemia,  in  which 


-Shows  the  Same  Uterus  seen  in  Fig.  130 
Removal  of  the  Myoma  from  its  Anterior 


512  FIBEOID    TUMOES. 

case  the  prime  indications  are  to  check  hemorrhage  and  avoid  a  protracted 
operation.  Myomectomy  is,  however,  a  more  dangerous  operation  than  hystero- 
myomectomy  (supravaginal  operation).  In  three  hundred  and  six  cases  of 
myomectomy  in  my  practice  there  was  a  mortality  of  four  and  a  half  per  cent 
in  contrast  to  a  mortality  of  three  and  one-tenth  per  cent  in  six  hundred  and 
ninety-one  eases  of  hysterectomy.  Xoble  {loc.  cit.,  pp.  711,  712)  gives  the 
mortality  of  myomectomy  in  the  hands  of  trained  gynecologists  as  from  three 
to  five  per  cent;  of  hysterectomy  (supravaginal  operation)  as  two  to  four  per 
cent :  and  of  total  hysterectomy  nearly  double  that  of  hystero-myomectomy.  In 
badly  complicated  cases  and  in  untrained  hands  the  mortality  of  these  opera- 
tions is  as  high  as  ten,  twenty,  or  even  thirty  per  cent. 

The  most  favorable  time  for  a  radical  operation  on  a  fibroid  tumor  is  just 
before  a  menstrual  period,  because  at  this  time  the  blood-making  organs  have 
had  the  best  opportimity  to  make  good  the  loss  of  blood,  and,  in  the  case  of 
tumors  causing  dysmenorrhea,  the  patient  has  had-  a  chance  to  rest  from  the 
depressing  effect  of  the  pain  of  the  last  period. 

FIBROID    TUMORS    AND    PREGNANCY. 

TThen  fibroid  tumors  are  associated  with  pregnancy  it  may  become  a  nice 
question  whether  to  let  the  patient  go  to  term,  or  to  provoke  an  abortion,  or 
to  do  a  radical  operation,  removing  the  uterus,  the  tumors,  and  the  ovum  all 
in  one  mass.  The  first  point  of  importance  in  such  a  contingency  is,  as  a  rule, 
to  realize  that  a  fibroid  tumor  is  not  a  serious  complication,  and  therefore  it 
bv  no  means  calls  for  interference  from  the  mere  fact  of  its  existence.  Again, 
if  the  case  is  watched  throughout  the  pregnancy  as  it  should  be,  the  danger  of 
non-interference  is  but  slight.  T\'hen  the  fibroid  gTowths  are  numerous,  nature 
eenei-allv  steps  in  herseK  to  relieve  the  situation  by  causing  a  spontaneous 
abortion. 

The  cases  which  require  interference  are  those  in  which  a  large  tmnor 
springs  from  the  cervix  and  chokes  the  pelvis  below  the  preg-nancy,  or  else  those 
in  which  a  tumor  springing  from  the  posterior  half  of  the  uterus  is  immovably 
wedged  in  the  pelvis.  Often  a  case  which  looks  grave  at  the  outset  rights  itself 
as  pregnancy  advances  by  the  ascent  of  the  tumor  and  requires  no  interference. 

Tumors  in  the  upper  part  of  the  uterus  do  not  often  complicate  pregnancy 
or  labor.  The  real  complication  in  large  tumors  begins  after  delivery,  when 
there  is  a  gTeater  liability  to  hemorrhage.  In  all  doubtful  cases,  perhaps  in  all 
cases  without  exception,  a  conservative  specialist  ought  to  be  consulted. 


CHAPTEE    XXI. 

CANCER  OF  THE  UTERUS.     DIAGNOSIS  AND   PALLIATIVE  TREATMENT. 

(1)  Etiology,  p.  513. 

(2)  Diagnosis:  Clinical  history,  p.  517.     Local  signs,  p.  520.     Microscopic  examination,  p.  525. 

(3)  Prophylaxis,  p.  530. 

(4)  Treatment:  Curettage,  p.  534;  cauterization,  p.  536;  X-ray,  p.  537;  radium,  p.  537;  methy- 

lene blue,  p.  538;   thjToid  extract,  p.  539;   trypsin,  p.  540;   acetone,  p.  540;  general 
remedial  measures,  p.  542. 

The  litems  is  by  far  the  most  frequent  seat  of  primary  cancer,  and  the 
disease  in  that  situation  is  so  prevalent  that  no  busy  general  practitioner  passes 
a  year  without  the  opportunity  of  observing  one  or  more  cases  in  his  own 
practice.  It  is  of  the  utmost  importance,  therefore,  that  the  physician  in  gen- 
eral practice  should  be  perfectly  informed  on  all  its  diagnostic  features,  for 
the  recog-nition  of  this  frightful  scourge  in  its  early  stages  depends  largely 
upon  him.  It  is  the  general  practitioner  also  who  must  bear  the  daily  burden 
of  treatment  in  cases  where  the  disease  is  not  discovered  until  it  is  too  late 
to  adopt  radical  measures  of  relief,  as  well  as  in  those  in  which  it  recurs  after 
a  futile  operation. 

The  ravages  of  the  disease  upon  the  contiguous  pelvic  organs  are  well  shown 
in  FigTire  132,  where  a  cancer  beginning  in  the  cervix  has  extended  up  into 
the  body  of  the  uterus ;  down  onto  the  vagina  forward  into  the  bladder,  form- 
ing a  vesico-vaginal  fistula ;  and  backward  into  the  rectum,  which  is  extensively 
involved.  If  we  could  see  the  lateral  extensions  also,  we  should  find  both  broad 
ligaments  choked  and  the  disease  extending  up  to  the  pelvic  walls. 

ETIOLOGY. 

The  etiology  of  cancer  is  a  subject  upon  which  the  general  practitioner 
should  be  carefully  posted,  in  order  that  he  may,  by  his  judicial  advice,  pre- 
vent injustice  being  done  to  an  already  overburdened  and  distressing  class  of 
sufferers.  Evidence  gathered  from  widely  spread  sources  shows  a  growing 
impression  among  the  laity  that  cancer  is  "  a  catching  disease."  This  notion 
is  fostered,  on  the  one  hand,  by  certain  physicians  who  draw  conclusions  from 
a  few  data  and  express  themselves  in  print  upon  a  subject  which  they  have 
not  studied  in  all  its  bearings ;  and,  on  the  other,  by  the  attitude  of  the  press 
throughout  the  country,  as  well  as  that  of  some  pseudo-medical  journals,  which 
seem  always  ready  to  foster  the  idea  that  cancer  is  contagious.  This  phase 
of  the  subject  has  been  carefully  investigated  by  W.  S.  Bainbridge  {Bost. 
34  513 


514 


CAXCEE    OF    THE    TTEEUS. 


Med.  and  Surg.  Jour.,  1907,  vol.  156,  p.  835),  and  I  give  a  brief  abstract  of 
rlie  principal  points  in  Lis  paper: 

"  Bainbridge  cites  the  familiar  question,  so  often  beard  in  the  consulting 
room :   '  Is  cancer  contagious  ? '   and  then  refers  to  a  case  in  Tvbicb  a  nurse 


Fig.  132. — Sqtjamots-celled  Carctn-oma  of  the  rER-^ix  vtjtr  Extension'  to  the  Bladder  antj 
Rectt^i  and  Formation  of  a  Vesico-vaginal  Fistitla.  (Natural  size.)  A  sagittal  section  of  the 
uterus,  bladder,  and  rectum.  The  upper  part  of  the  vagina  and  the  greater  part  of  the  body  of  the 
uterus  are  occupied  by  a  new  gro-«-th  and  the  ceirical  landmarks  are  entirely  obliterated.  At  the 
cer\-ieal  site  the  gro-n-th  has  broken  do-mi;  its  upper  margin  is  irregular  but  sharply  defined,  and 
stands  out  clearly  from  the  uterine  muscle,  Trhich  is  much  darker  in  color.  Along  the  lower  or 
vaginal  limit  the  growth  is  considerablv  elevated  and  overhangs  the  normal  mucosa.  At  the  point 
where  the  carcinoma  has  implicated  the  bladder  it  measures  over  1  cm.  in  thickness  and  extends 
downwards  to  the  inner  urethral  orifice.  At  the  trigonum  the  bladder  wall  has  broken  down,  with 
the  formation  of  a  vesico- vaginal  fistula  1.5  cm.  in  diameter  with  ragged  margins.  The  mouth  of 
ureter,  which  is  surrounded  by  a  little  mound  of  carcinomatous  tissue,  is  seen  a  short  distance  ■within 
the  inner  urethral  orifice.  In  such  a  case  as  this  the  bladder  is  not  usually  so  large,  as  it  commonly 
undergoes  contraction  after  a  fistula  is  formed  from  lack  of  the  usual  distention. 


ETIOLOGY.  515 

expressed  lier  determination  never  to  nurse  another  cancer  patient,  on  account 
of  the  personal  danger  incurred  by  doing  so.  In  another  instance,  a  patient 
with  cancer  was  practically  evicted  by  fellow-boarders  afraid  of  acquiring 
the  disease.  A  still  graver  case  is  one  in  which  the  entire  corps  of  nurses 
in  a  hospital  in  the  County  of  Kings,  ISTew  York,  struck  in  a  body,  posi- 
tively refusing  to  remain  in  the  hospital  if  required  to  take  care  of  a  can- 
cer case. 

There  can  be  no  doubt  that  this  notion  of  the  contagiousness  of  cancer  is 
in  part  fostered  by  the  recent  reversal  of  the  attitude  of  the  entire  medical 
profession  towards  the  tuberculosis  question.  Only  a  generation  ago,  it  was 
positively  held  that  tuberculosis  was  in  no  sense  either  contagious  or  infectious, 
v/hile  to-day  a  high  degree  of  both  contagiousness  and  infectiousness  is  recog- 
nized. The  argument  by  analogy  from  tuberculosis  to  cancer  is  too  strong  to 
be  resisted  by  the  laity. 

Three  factors,   says  Bainbridge,   play   an  important  role   in  the   etiology 

of  cancer: 

(1)  Heredity. 

(2)  Congenital  transmission. 

(3)  Infectiousness  or  contagiousness. 

While  there  are  some  well-authenticated  instances  of  the  remarkable  preva- 
lence of  malignant  tumors  in  families  within  a  few  generations,  nothing 
has  been  proven  from  tliese  data  beyond  the  fact  that  there  may  exist  the 
same  hereditary  predisposition,  found  in  many  other  forms  of  disease,  such 
as  infections,  cerebral  apoplexy,  etc.  An  hereditary  influence  can  be  traced  in 
from  one-third  to  one-fourth  of  the  cases.  Roger  WiUiams,  in  1892,  reported 
one  hundred  and  thirty-six  cases  of  carcinoma  of  the  breast,  with  a  history 
of  heredity  in  twenty -nine  and  two-tenths  per  cent ;  there  were  forty-eight 
cases  in  thirty-three  families.  He  cites  among  others  the  well-known  fact 
that  the  father,  the  brother,  and  two  sisters  of  ]^apoleon  all  died  of  can- 
cer of  the  stomach,  to  which  he  himself  finally  succumbed.  Broca  records 
sixteen  deaths  from  cancer  in  a  family  of  twenty-seven  members.  Chante- 
messe  and  Podwyssotsky  declare  that  heredity  in  the  case  of  a  neoplasm  is  in 
reality  but  an  inheritance  of  a  predisposition  to  allow  of  the  implantation 
of  the  parasite  which  they  consider  the  true  cause  of  the  disease.  Bainbridge 
urges  that  most  of  the  arguments  used  to  prove  heredity  can  be  employed 
with  equal  force  to  demonstrate  a  transmission  by  infection.  Conclusive  evi- 
dence on  either  side  can  be  reached  only  after  further  investigations. 

Cohnheim  was  the  originator  of  the  theory  that  in  course  of  development 
certain  cells  were  misplaced  into  tissues  where  they  did  not  normally  belong, 
and  that  it  is  from  these  misplaced  cells  that  tumors  take  their  origin.  This 
interesting  speculation,  although  widely  discussed,  has  not,  as  yet,  received 
positive  confirmation. 

Belief  in  contagion  rests  upon  four  things: 


516  CAlSrCER    OF    THE    UTERUS. 

(1)  TLe  theory  of  the  contagiousness  or  infectiousness  of  malignant 
tumors  in  mice. 

(2)  The  transmissibility  of  the  Jensen  mouse  tumor. 

(3)  Inoculation  experiments. 

(4)  Tlie  reports  of  cases  of  coexistent  or  coincident  cancer  in  families  of 
human  beings,  supposed  to  be  the  result  of  accidental  infection.  In  a  disease 
so  excessively  common,  the  instances  of  coincident  cancer  occurring  in  people 
brought  frequently  into  close  contact  with  one  another  may  readily  be  dis- 
posed of  as  mere  accidental  coincidences.  As  to  the  transmission  of  malignant 
tumors  by  means  of  experimental  propagation,  as  Bashford  has  said,  this 
demonstrates  nothing  more  than  that  the  cells  of  the  tumor  in  one  animal  con- 
tinue to  proliferate  in  another  animal,  and  this  affords  no  proof  touching 
the  contagiousness  or  infectiousness  of  cancer  in  general.  'No  facts  have  yet 
been  adduced  which  prove  that  cancer  can  be  conveyed  by  the  ordinary  contacts 
of  human  life. 

In  the  present  status  of  our  knowledge,  it  is  sufficient  for  the  general  prac- 
titioner to  insist,  on  the  one  hand,  that  there  is  no  danger  of  any  member  of 
the  family  catching  the  disease ;  ■  and,  on  the  other,  to  recommend  that  the 
same  care  and  precaution  should  be  taken  as  are  proper  during  the  treatment 
of  any  infected  wound,  for  the  protection  of  the  healthy  from  contact  and  con- 
tamination. The  cancerous  wound  should  be  kept  as  clean  as  possible  by  fre- 
quent cleansing;  those  who  handle  it  should  do  so  with  protected  hands,  using 
forceps  and  other  instruments  as  far  as  possible,  while  the  cloths  employed  for 
dressings  on  the  diseased  surface  must  be  burned  immediately.  Douching 
vessels  must  be  kept  for  the  patient's  exclusive  use  and  articles  of  clothing 
worn  by  her  should  not  be  put  on  b}^  others.  It  is  better  for  a  patient  with 
cancer  to  occupy  her  own  bed  and  use  her  o^vn  separate  bed-linen.  Such  rea- 
sonable care  as  this  will  satisfy  the  laity  that  everything  possible  is  being 
done,  and  thereby  secure  their  confidence  when  assured  that  the  situation  calls 
for  nothing  more.  By  doing  this  we  shall  avoid  imposing  unnecessary  burdens 
upon  sufferers  who  are  already  sufficiently  pitiable,  without  the  distress  of 
complete  seclusion  and  ostracism,  not  to  say  neglect. 

In  regard  to  the  question  of  heredity  I  may  say  here  that  in  forty  out 
of  forty-nine  cases  of  squamous-celled  cancer  of  the  cervix  treated  at  the  Johns 
Hopkins  Hospital,  no  history  whatever  could  be  obtained  of  malignant  disease 
in  the  family ;  and  in  only  two  of  the  remaining  nine  was  there  any  record 
of  cancer  in  the  uterus.  In  eighty-two  per  cent  of  these  cases,  therefore, 
hereditary  influence  could  be  excluded.  In  thirteen  cases  of  adeno-carcinoma 
of  the  fundus  there  were  only  two  where  cancer  had  occurred  among  near 
relatives,  and  in  neither  of  these  was  it  situated  in  the  uterus.  These  fig- 
ures, it  will  be  seen,  are  even  less  favorable  to  hereditary  influence  than  those 
cited  above. 

Trauma. — There  is  a  strong  impression  in  lay  circles  that  trauma  plays 
an  important  part  in  the  causation  of  all  forms  of  malignant  disease,  which 


DIAGTiTOSIS    FEOM    CLINICAL    HISTORY.  517 

seems  to  be  borne  out  in  the  case  of  cancer  of  the  breast  and  of  the  nterns. 
There  is  no  donbt  that  the  injuries  inflicted  upon  the  cervix 
uteri  during  labor  are  a  definite  causal  factor  in  subsequent 
cervical  carcinoma.  ISTinety-eight  per  cent  of  the  cases  of  squamous- 
celled  carcinoma  of  the  cervix  in  my  clinic  at  the  Johns  Hopkins  Hospital 
had  had  children,  so  that  the  proportion  of  cases  in  nulliparae  was  extremely 
small.  In  my  private  practice  I  have  seen,  in  all,  but  three  cases  of  cervical 
cancer  in  nulliparae,  and  in  one  of  these  the  cervix  had  been  forcibly  dilated. 
Emmet  mentions  the  occurrence  of  a  cervical  cancer  in  a  woman  who  had 
never  had  children,  and  here  also  the  cervix  had  been  dilated.  My  associate, 
Dr.  C  F,  Burnam,  however,  has  recently  had  a  case  in  a  nullipara  where 
there  had  never  been  any  operation  on  the  cervix,  and  similar  cases  have  been 
reported  by  W.  H.  Weir  (Amer.  Jour.  Obst.,  1900,  vol.  42,  p.  377)  and  others. 
H.  J.  Boldt  has  been  able  to  demonstrate  the  disease  in  its  very  incipiency  in 
a  laceration  of  the  cervix.  In  advance  of  the  local  examination  the  fact  that 
the  patient  is  a  nullipara  is  always  strong  presumptive  proof  against  cancer 
of  the  cervix  uteri. 

DIAGNOSIS. 

In  making  a  diagnosis  of  uterine  cancer  three  lines  of  investigation  must 
be  considered,  namely,  the  clinical  history  ;  the  local  signs  ;  and  the 
microscopic  examination.  The  local  signs  and  the  microscopic  exam- 
ination afford  the  most  accurate  information,  but  the  clinical  history  is  not 
without  great  significance. 

CLINICAL    HISTORY. 

Age. — All  statistics  conspire  to  prove  that  cancer  of  the  uterus  is  most 
frequent  about  the  time  of  the  menopause.  R.  R.  Huggins  suggests  that  the 
injuries  sustained  by  the  uterus  during  parturition  render  the  cervix  unusually 
susceptible  to  cancerous  disease  during  the  years  when  the  degenerative  changes 
accompanying  the  menopause  are  taking  place.  Before  the  cessation  of  men- 
struation the  number  of  cases  of  cervical  cancer  is  relatively  larger  than  the 
cases  of  cancer  of  the  fundus,  whereas  after  menstruation  has  ceased,  the  oppo- 
site is  true.  Squamous-celled  carcinoma  may  occur  even  in  the  twenties,  but 
this  is  exceptional.  Since  the  year  1900  I  have  seen  several  cases  of  cancer 
of  the  cervix  at  the  Johns  Hopkins  Hospital  in  patients  between  twenty  and 
thirty  years  old.  Not  many  cases,  however,  begin  either  before  forty  or 
after  sixty. 

Menstrual  History. — Menstruation  is  usually  regular  until  the  carcinoma 
begins  to  become  active,  and  then,  as  a  rule,  it  is  profuse.  In  those  patients 
who  have  passed  the  menopause  before  the  carcinoma  appears  there  is  usually 
a  history  of  normal  regular  menstruation  up  to  the  time  of  cessation.  There 
does  not  appear  to  be  any  relation  between  menstruation  and  the  occurrence 
of  cancer. 


518  CANCER    OF    THE    UTERUS. 

Vaginal  Discharge. — A  discliarge  is  present  in  all  forms  of  cancer  and  it 
may  be  the  first  symptom  of  the  disease.  In  cancer  of  the  fundus  it  often 
appears  before  the  hemorrhage.  It  is  usually  thin,  watery,  colorless, 
and  irritating,  and  sometimes  has  a  characteristic  penetrating  odor. 
Occasionally  it  is  purulent  and  often  it  is  blood  stained.  A  bloody 
stinking  ooze  characterizes  the  last  stages  of  a  cervical  growth. 

Hemorrhage. — Loss  of  blood  is  perhaps  the  most  important  symptom  of 
cancer  and  should  not  fail  to  receive  immediate  attention.  Before  the  meno- 
jDause  it  may  occur  with  the  menstrual  j)eriods,  as  an  "increase  in  amount  or 
an  extension  of  duration;  or  there  may  be  more  or  less  profuse  hemorrhage 
during  the  intervals.  In  cervical  cancer  the  bleeding  is  apt  to  come  on  sud- 
denly after  some  unusual  exertion,  as  lifting  a  heavy  weight ;  after  coitus ;  or 
with  defecation.  It  is  an  earlier  and  more  frequent  sjonptom  in  cancer  of  the 
cervix  than  in  cancer  of  the  fundus. 

Pain. — In  the  early  stages  of  carcinoma  patients  rarely  complain  of  much 
suffering;  with  further  progress,  however,  there  is  a  persistent,  dull, 
heavy  pain  in  the  back  or  cramp-like  pains  in  the  uterus;  as  the  disease 
advances  and  the  growth  presses  upon  adjacent  organs  and  nerve  trunks,  the 
pain  extends  to  the  thighs,  the  knees,  and  even  to  the  calves  of  the  legs,  follow- 
ing the  course  of  the  sciatic  nerves.  Cases  are  occasionally  seen  in  which  there 
is  no  pain  throughout,  but,  as  a  rule,  the  suffering  in  the  latter  stages  is  a 
marked  and  peculiarly  distressing  feature. 

Emaciation. —  Loss  of  flesh  is  rarely  well  marked  in  the  early  stages  of 
uterine  cancer,  indeed,  the  fact  that  the  patient  has  lost  flesh  is  good  evidence 
that  the  disease  has  made  progress ;  in  some  cases  the  body  remains  well  nour- 
ished even  to  the  end.  The  degree  of  emaciation  depends  upon  the  condition 
of  the  patient's  appetite  as  well  as  upon  the  direct  effect  of  the  disease  and 
the  absorption  of  toxines  upon  the  metabolism  of  the  body. 

Cachexia. — There  is  a  peculiar  lemon-colored  appearance  of  the  skin  which 
is  characteristic  of  malignant  disease  of  all  kinds  and  is  most  suggestive  to 
the  practised  eye.  It  is  due,  according  to  Klemperer  {Cliarite  Annalen,  vol. 
16,  p.  138),  to  the  fact  that  more  nitrogen  leaves  the  body  than  is  taken  in. 
Like  emaciation,  it  is  a  symptom  of  the  later  stages. 

Any  woman  between  thirty-five  and  sixty  who  comes  to  the  physician 
complaining  of  increased  menstruation,  of  metrorrhagia,  of  pelvic 
pain,  or  of  vaginal  discharge  should  be  examined  without  loss  of  time 
on  the  suspicion  of  cancer.  The  old-fashioned  jDractice  of  treating  her  ten- 
tatively for  a  time,  in  the  hope  that  the  symptoms  will  subside,  cannot  be  too 
strongly  condemned.  If  cancer  of  the  cervix  exists  it  can  easily  be 
recognized,  even  in  its  earliest  stages.  It  is  well  to  remember  that  an  ulcera- 
tion of  the  cervix  at  that  age  is  practically  always  cancerous, 
bearing  in  mind  that  an  "^erosion"  is  not  an  ulceration.  If  there 
is  no  evidence  of  cancer  of  the  cervix,  and  no  definite  cause  for  the  symptoms 
can  be  found,  the  uterus  should  be  curetted  and  the  scrapings  examined  with 


DIAGNOSIS    FKOM    CLINICAL    HISTORY.  519 

the  microscope.  It  is  well  to  remember  that  it  is  sometimes  necessary  to 
examine  many  slides,  and  even  to  cnrette  more  than  once  before  the  evidence 
of  cancer  is  secured.  The  earlier  the  stage  and  the  more  limited  the  disease, 
the  more  difficult  it  is  to  find. 

G.  E.  Shoemaker  (N.  Y.  Med.  Jour.,  1905,  vol.  83,  p.  1092)  mentions  a 
case  in  which  a  woman  of  forty,  who  had  had  nine  children,  complained  of 
constant  uterine  hemorrhage  for  three  months.  On  examination  the  uterus 
was  found  enlarged,  and  curettage  was  therefore  done  to  confirm  or  confute  the 
susj^icion  of  cancer.  A  grating  sensation  was  noticed  near  the  fundus,  but  on 
microscopic  examination  at  first  no  cancer  was  found;  then  after  a  number 
of  slides  had  been  studied  the  evidence  was  forthcoming,  and  a  hysterectomy 
was  performed,  when  it  proved  that  the  only  spot  where  the  malignant  disease 
existed  was  a  little  nodule,  hardly  larger  than  a  grain  of  corn,  in  the  upper 
third  of  the  uterus. 

A  most  potent  cause  of  failure  in  the  treatment  of  uterine 
cancer  is  neglect  on  the  part  of  the  patient  to  apply  for  advice 
until  the  disease  is  so  far  advanced  that  an  operation  offers  no 
hope.  It  becomes  a  matter  of  vital  importance,  then,  that  the  public  should 
be  well  informed  as  to  the  symptoms  which  ought  to  excite  suspicion,  and 
which  proclaim  the  necessity  for  immediate  competent  medical  investigation. 

D.  H.  Craig  (N.  Y.  Med.  Jour.,  1905,  vol.  82,  p.  65)  investigated  the 
histories  of  seventy-eight  cases  of  uterine  cancer  and  found  that  in  forty-five 
of  them  the  first  symptom  noticed  by  the  patient  was  a  leucorrhea;  in 
twenty-two  cases  it  was  hemorrhage,  varying  in  amount  from  the  slightest 
stain  to  profuse  bleeding;  while  in  the  remaining  twelve  cases,  pain  was 
experienced  several  weeks  before  any  other  indication  appeared.  The  presence 
of  any  one  of  these  three  symptoms  should  never  be  overlooked  in  a  woman 
over  thirty-five.  A  certain  difficulty,  however,  as  Craig  points  out,  arises  from 
the  fact  that  in  the  earliest  stages  of  cancer  the  vaginal  discharge  has  no  spe- 
cial characteristics  which  may  serve  to  distinguish  it  from  the  leucorrheas 
with  which  the  majority  of  women  suffer. 

The  education  of  the  public  mind  on  this  question  is  peculiarly  important 
on  account  of  the  prevailing  impression  that  irregularities  of  menstruation 
and  the  existence  of  vaginal  discharges  are  a  feature  of  the  normal  menopause 
and  must  be  accepted  as  a  matter  of  course.  Even  metrorrhagia  receives  sur- 
prisingly little  attention,  because  accounted  for  in  the  same  way.  In  women 
who  have  passed  the  menopause  there  is  a  sort  of  reckless  tendency  to  ascribe 
any  hemorrhage  from  the  vagina  to  a  return  of  menstruation.  But  as  Shoe- 
maker observes  (loc.  cit.)  "when  a  year  or  two  has  passed  after  a  normally 
established  menopause,  the  appearance  of  blood,  if  only  a  small  spot,  from  the 
genitalia  often  means  cancer.  It  need  not  be  persistent ;  it  need  not  be  abun- 
dant ;  its  very  presence  more  than  a  year  after  the  menopause  is  sufficient  to 
arouse  grave  apprehensions  of  malignant  disease." 

The  specialist  occasionally  sees  a  far  advanced  case  of  carcinoma,  either 


520  CANCER    OP    THE    UTEEUS. 

of  the  fundus  or  the  cervix,  from  which  the  jDatient  has  noticed  symptoms 
only  Avithin  three  or  four  weeks.  Such  experiences  generally  occur  with  women 
wlio  have  nearly  reached  the  menopause  and  make  imperative  the  solemn 
command  to  every  physician  to  investigate  at  the  earliest  oppor- 
tunity  any   sign   or    symptom   referable   to   the   pelvic    organs. 

The  instruction  of  the  public  at  large  as  to  these  facts  is  the  duty  of  the 
general  practitioner  and  by  its  performance  he  has  it  within  his  power  to  save 
manv  lives.  The  only  cure  for  cancer  of  the  uterus  is  extirpation,  and 
statistics  show  that  when  the  case  is  in  the  surgeon's  hands  sufficiently  early, 
the  number  of  permanent  cures  is  by  no  means  small.  Eighty  per  cent  of  the 
cancers  of  the  fundus  of  the  uterus  at  the  Johns  Hopkins  Hospital  were  per- 
manently cured;  and,  while  the  figures  as  to  cancer  of  the  cervix  are  not  so 
encouraging,  being  fifteen  to  eighteen  per  cent  cured,  this  percentage  will  be 
largely  increased  when  the  necessity  for  early  operation  is  widely  appreciated 
by  the  medical  profession  and  the  laity  at  large. 

There  can  be  no  doubt  that  the  most  important  agent  in  the  instruction 
of  the  public  is  the  general  practitioner.  Almost  all  women,  and  married 
women  especially,  have  a  more  or  less  intimate  acquaintance  with  some  physi- 
cian with  whom  they  converse  at  one  time  or  another  on  the  subject  of  their 
own  health  or  that  of  their  relatives,  and  in  whose  opinion  they  place  great 
confidence.  If  every  family  physician  would  make  it  a  point  to 
take  advantage  of  the  opportunities  afforded  him  by  such  rela- 
tions, to  point  out  the  significance  of  hemorrhage,  vaginal  dis- 
charge, and  pelvic  pain  occurring  about  the  time  of  the  meno- 
pause, he  would  accomplish  more  towards  diminishing  the  death 
rate  of  cancer  than  can  be  done  by  any  other  means  we  can  com- 
mand at  present. 

LOCAL    SIGNS. 

Two  kinds  of  cancer  are  found  in  the  uterus:  (1)  those  which  begin  to 
STOW  in  the  cervix  (see  Fig.  133),  and  (2)  those  which  start  in  the  body  of  the 
uterus,  at  some  point  above  the  internal  os  uteri  (see  Fig.  131).  The  great 
practical  difference  between  the  two  lies  in  their  radically  different  clinical 
course,  cancer  of  the  body  gTowing  slowly,  affecting  the  glands,  and  extending 
outwards  only  in  the  later  stages,  while  cancer  of  the  cervix  affects  the  glands 
early,  and  spreads  with  the  utmost  rapidity  into  the  neighboring  tissues. 

Cancer  of  the  Cervix. — On  making  a  vaginal  examination  in  cancer  of  the 
cervix  the  conditions  which  the  examiner  finds  vary  greatly  according  to  the 
stage  of  the  disease,  which  may  conveniently  be  divided  into  three  classes: 
(1)  of  enlargement;  (2)  of  breaking  down;  (3)  of  craterous  excavation. 
These  various  locations  and  the  course  of  a  cervical  cancer  are  shown  in  Fig- 
ures 135,  136,  137,  138,  139,  140  and  111. 

In  the  first  stage  the  cervix  is  slightly  enlarged,  or  one  of  the 
lips  appears   nodular,    puffy,    and  has  a   slightly   glazed    appearance, 


Fig.  133. — Sqtjamoxjs-celled  Carcinoma  of  the  Cervix;  Carcinomatous  Mass  Springing  from  the 
Anterior  Lip.  (|  natural  size.)  Uterus  opened  and  showing  the  posterior  aspect.  A  cauliflower 
growth  is  seen  on  the  cervix ;  the  uterine  tubes  and  the  ovaries  are  uninvolved. 


Fig.  134. — Adeno-carcinoma  of  the  Body  of  the  Uterus  with  Extension  to  the  Left  Roxtnd 
'  Ligament,  (f  natural  size.)  The  uterus  was  nearly  twice  its  normal  size.  The  cervix  and  the 
lower  part  of  the  bodv  present  the  usual  appearance,  but  the  upper  half  of  the  body  is  occupied  by  a 
friable-looking  growth  which  has  involved  the  entire  thickness  of  the  uterine  walls  (a).  In  the  left 
round  ligament  is  a  definite  nodule  (b),  while  between  the  left  tube  and  ovary,  and  followmg  the 
course  of  the  lymph  channels  from  the  body  of  the  uterus,  are  three  small,  oval,  carcmomatous 
nodules  (c).     The  appendages  on  both  sides  appear  to  be  normal.      (After  W.  W.  Russell.) 

521 


522 


CANCER    OF    THE    UTEKUS. 


with  one  or  more  enlarged  vessels  coursing  over  it,  and  perhaps  a  few  teat- 
like processes  projecting  from  its  surface.  The  examining  finger  usu- 
ally brings  away  a  little  blood,  which 
is  most  significant.  In  some  patients,  seen 
early,  this  is  all  that  can  be  found;  or,  possi- 
bly, there  is  already  a  small  mulberry-like  mass. 
In  many  instances,  unfortunately,  the  vagina  is 
already  more  or  less  filled  with  a  cauliflower 
gTowth  which  is  extremely  friable,  breaks 
down  under  the  examining  finger,  and  at  times 
bleeds  profusely.  If  this  growth  is  traced  to 
its  attachment  it  will  be  found  springing  from 
one  of  the  lips  of  the  cervix.  In  the  first  stage 
of  the  disease  this  cervical  involvement  is  all 
that  can  be  found,  the  vaginal  mucous  mem- 
brane below  the  cervix  appears  normal,  there  is 
no  thickening  in  either  of  the  broad  ligaments, 
and  the  uterus  still  remains  freely  movable, 
unless  fixed  by  some  associated  inflammatory 
process. 

In  the  second  stage  the  growth  has  begun  to  break  down  and 
disappear.  The  margins  of  the  cervical  lips  are  swollen  and  livid  and 
within  the  margin  is  a  rough,  uneven,  scooped-out  area  readily  detected  by 


Fig.  135. — Illustrates  the  Three 
Principal  Foci  from  which  Car- 

CIXOMA  OF  THE  UtERUS  TAKES  ItS 

Origin. 


Fig.  136. — Earlt  Stage  of  Sqttamotjs-celled 
Carcinoma  of  the  Cervix  —  Everting 
Type. 


Fig.  137. — More  Advanced  Stage  of  the  Disease 
SEEN  IN  Fig.  136.  The  cancer  has  invaded  both 
Ups  and  extended  to  the  posterior  vaginal  vault. 


the  finger.     The  induration  often  extends  out  onto  the  vaginal  vault  and  doT^^l 
its  walls,  and  by  the  time  these  changes  have  occurred,  there  is  almost  always 


DIAGNOSIS    FKOM    LOCAL    SIGNS. 


523 


some  decided  coincident  thickening  of  one  or  both  broad  ligaments.     Examina- 
tion with  the  speculum  shows  a  ragged  bloody  excavation  covered  here  and 


Fig.  138. — Earlt  Stage  of  Sqttamous-celled 
Carcinoma  of  the  Cervix.  Infiltrating 
type. 


Fig.  139. — More  Advanced  Stage  of  Disease  Seen 
in  Fig.  138,  showing  the  Breaking  down  in 
THE  Center  and  the  Formation  of  a  Crater. 


there  with  necrotic  tissues.  The  advancing  margin  of  growth  is  marked  by 
a  hard  ridge  covered  with  the  vaginal  mucosa.  The  body  of  the  uterus,  as  a 
rule,  remains  unchanged  in  cervical  cancer.     Sometimes  it  is  as  large  as  a  two 


Fig.  140. — Early  Stage  of  Columnar-celled 
Cancer  of  the  Cervical  Canal.  The  dis- 
ease is  not  manifest  to  inspection  of  the  cer- 
vix but  to  the  toucli  of  the  cervix  feels  great- 
ly thickened. 


Fig.  141. — More  Advanced  Stage  of  Disease  seen 
IN  Fig.  140.  A  crater-like  cavity  is  formed.  The 
progress  of  the  growth  of  carcinoma  of  the  cervix 
is  shown  in  more  detail  in  "Studies  in  Gynecol- 
ogy," by  J.  A.  Sampson,  1907. 


or  three  months'  pregnancy,  reaches  up  as  far  as  the  pelvic  brim,  and  has  a 
tense  elastic  feel,  o^ving  to  an  accumulation  of  pus  in  the  uterine  cavity. 


524 


CANCER    OF    THE    UTEETTS. 


Again,  at  a  later  stage  all  trace  of  tlie  cervix  will  have  disap- 
peared, and  the  vaginal  vault  is  occupied  by  a  hole  surrounded  by  a 
puckered,  hard,  nodular  tissue,  while  from  the  opening  issues  a  foul 
brownish  discharge.  The  mucosa  of  the  surrounding  vaginal  vault  is  often 
intact,  but  the  underlying  tissue  is  indurated,  owing  to  the  extension  of  the 
gTOwth,  while  isolated  nodules  are  seen  and  felt  lying  just  underneath  the 
mucosa  in  any  portion  of  the  vagina.  Sometimes  the  entire  vaginal  vault  is 
enlarged  and  lined  by  a  necrotic  and  friable  carcinomatous  tissue,  while  the 


Fig.  142. — Diagram  showikg  a?s-  Extremely  Advanced  Stage  of  Cervical  Carcinoma,  in  -ktiich 
THE  Disease  has  Advanced  to  the  Bladder  and  the  Rectum. 


surface  of  the  vaginal  mucosa  is  covered  by  little  shaggy  tufts  of  the  can- 
cerous gTOwth.  In  more  advanced  stages  all  anatomical  relations  are 
lost;  the  entire  upper  part  of  the  vagina  is  choked  with  the  cancer,  and 
the  urine  trickles  down  into  the  vagina  through  a  vesico-vaginal  fistula; 
the  rectum  may  be  involved  and  the  feces  pass  also  per  vaginam  (see 
Fig.   142). 

I  often  see  cases  brought  in  consultation,  it  may  be  from  a  distance,  in 


DIAGNOSIS    FROM    MICEOSCOPIC    EXAMINATION.  525 

which  the  physician  has  mistaken  a  red  everted  cervix  (so-called  "erosion")  ; 
or  a  cervix  covered  with  multiple,  red,  plaque-like,  bleeding  areas;  or  a  hard 
nodular  everted  cervix  containing  multiple  cysts  (ISTabothian  follicles),  for 
a  cancer. 

These  cases  can  be  distinguished  from  cancer  by  the  following  marks:  In 
the  everted  mucosa,  the  longitudinal  striae  can  often  be  seen  on  the  smooth 
glistening  mucosa,  and  this  shows  no  particular  liability  to  bleed  upon  handling. 
The  plaque-like  areas,  which  are  so  prone  to  bleed,  are  in  reality  super- 
ficial erosions,  but  differ  from  cancer  in  being  superficial  and  isolated  or  mul- 
ti]3le.  The  jSTabothian  cysts  are  easily  recognized  by  puncturing  them  with 
a  sharp-pointed  scarifier,  when  the  mucilaginous  contents  escape  and  the  cyst 
collapses;  they  may  feel  like  shot  and  are  isolated  and  covered  wuth  velvety 
mucosa.  In  general  the  cancer  is  hard  and  granular,  breaking  down  under 
the  finger,  and  bleeding  readily. 

Cancer  of  the  Fundus. — In  cancer  of  the  fundus  the  body  of  the  uterus 
may  be  enlarged  to  the  size  of  a  three  months'  pregnancy,  while 
at  other  times  it  is  nearly  or  quite  the  normal  size.  The  diagnosis 
in  the  early  stages  of  cancer  of  the  fundus  must  depend  almost  entirely  upon 
the  history,  and  upon  a  microscopical  examination  of  scrapings  from  the  endo- 
metrium. It  is,  in  fact,  in  this  variety  of  cancer  that  curettage  is  of  such 
importance.  The  diagnosis  of  cervical  cancer  is  easily  made  from  the  visible 
and  tangible  local  signs,  while  the  disease  is  still  in  a  sufficiently  early  stage 
for  radical  operation  to  offer  prospect  of  a  cure,  but  in  cancer  of  the  fundus 
the  only  means  of  accurate  diagnosis  in  the  early  stages  is  the  microscopical 
examination  of  scrapings  from  the  mucosa.  In  the  later  stages  the  palpation 
of  alternate  hard  and  soft  areas  in  the  enlarged  fundus  helps  to  distinguish 
the  disease  from  myoma.  In  rare  instances,  carcinoma  of  the  fundus  pro- 
jects through  the  cervix  as  a  rounded  or  pyriform  mass  and  simulates  a  sub-« 
mucous  fibroid.  My  associate.  Dr.  Guy  L.  Hunner,  had  such  a  case,  in  a 
woman  of  sixty-one  years  of  age,  who  had  had  irregular  bleeding  for  eleven 
years;  and  the  true  nature  of  the  growth  was  not  suspected  until  the  patient 
was  anesthetized,  when  the  tumor  was  found  to  have  a  broad  origin  in  the 
fundus,  and  bimanual  examination  demonstrated  hard  and  soft  areas  through- 
out the  uterine  walls. 

MICROSCOPIC    EXAMINATION. 

If  cancer  of  the  cervix  is  suspected,  a  wedge-shaped  piece  is  removed 
for  microscopic  examination;  when  cancer  of  the  fundus  is  in  question, 
the  cavity  of  the  uterus  is  curetted  and  the  scrapings  examined  by  the  micro- 
scope. When  a  piece  of  the  cervix  is  to  be  removed,  the  cervix  is  drawn  down 
by  bullet  forceps,  and  a  wedge-shaped  piece,  about  one  centimetre  broad  at  the 
base  and  one  centimetre  in  length  from  base  to  apex,  is  excised  with  a  sharp 
knife.  The  raw  surface  is  then  cauterized  to  stop  hemorrhage  or  it  is  approx- 
imated by  two  or  three  silk  or  catgut  sutures.     As  a  rule  this  operation  is  not 


526 


CAliTCER    OF    THE    UTEErS. 


painful,  but  if  any  pain  is  felt  a  syringe  full  of  a  weak  cocain  solution  (1 :  500) 
injected  into  the  cervix  -will  obtund  sensation. 

The  operation  of  curettage  of  tlie  fundus  (see  Fig.  143)  has  been  already 
described  in  Chapter  VII  (see  p.  189),  but  it  is  of  great  importance  that  it 
should  be  performed  with  extreme  thoroughness,  since  it  may  hap- 
pen, in  an  early  stage  of  the  disease,  that  the  diseased  tissue  is  the  only  portion 
left  behind.  The  curettings  must  be  caught  by  the  spoon  as  they  emerge  from 
the  external  os,  and  placed  at  once  in  the  hardening  fluid 
(formalin,  ten  per  cent).  If  the  curettings  should  demon- 
strate a  malignant  disease,  no  time  should  be  lost  in  send- 
ing the  patient  to  a  specialist  for  radical  operation.  There 
is  an  impression  among  some  surgeons  that  curettage  tends 
to  hasten  the  extension  of  the  disease,  but  in  our  gyneco- 
logical work  we  cannot  avoid  it. 

The  tissues  may  be  studied  at  once  by  the  method 
described  in  Chapter  VII  (see  p.  192)  ;  or  they  may  be 
placed  in  a  hardening  medium  and  studied  at  leisure.  In 
cases  where  the  services  of  an  experienced  pathologist  can- 
not be  secured  and  the  physician's  knowledge  of  pathology 
is  not  sufficient  for  so  important  a  task,  the  specimens  can 
be  sent  in  the  hardening  medium  to  one  of  the  large  hos- 
pitals and  an  opinion  obtained  from  the  pathologist  con- 
nected with  it.  It  is  practically  impossible  by  description, 
even  with  the  best  illustrations,  to  equip  the  average  prac- 
titioner with  the  ability  for  making  a  certain  microscopical 
diagnosis  of  cancer  of  the  uterus.  It  is  true  that  with  the 
courses  in  histology  and  pathology  now  offered  in  most  of 
our  jDOst-graduate  medical  schools,  the  graduate  shoidd  be 
able  to  easily  identify  the  characteristic  microscopic  sec- 
tion of  cancer  of  the  uterus ;  but  not  all  microscopic  sec- 
tions, even  in  pronounced  carcinoma,  are  characteristic, 
and  there  are  many  conditions  of  the  cervix  and  endo- 
metrium, such  as  hypertrophies,  inflammations, 
polypoid  growths,  hypertrophy  of  the  glands, 
etc.,  which  yield  microscopic  sections  so  suggestive  of  car- 
cinoma that  none  but  the  experienced  pathologist  should 
be  trusted  with  the  final  opinion.  Special  warning  is  in 
order  at  this  time  because  of  the  many  pathological  labo- 
ratories now  being  conducted,  often  by  drug  firms,  on  a 
purely  commercial  basis.  Xo  physician  should  trust 
the  report  of  a  laboratory  without  knowing  posi- 
pathologist  making  the  report  has  had  special 
examination    of    uterine    scrapings. 


Fig.  143. — Large,  Ser- 
rated, Toothed  Cx'- 
rette,  t\"ith  opexixg 
THRoroH  THE  Han- 
dle BY  wHi  CH  Irriga- 
tion OF  THE  UTERrS 

CAN  BE  Carried  Oitt 
at  the  Saiie  Time  as 
the  Curetting. 


tively    that 
trainina:    in 


the 
the 


In  makino-  an  examination  it  is  alwavs  well  for  the  examiner  to  refresh 


DIAGNOSIS    FROM    MICROSCOPIC    EXAMINATION.  527 

his  memory  as  to  the  normal  appearance  of  the  tissues  to  be  examined  and 
also  to  follow  some  systematic  method  of  examination. 

When  the  piece  excised  from  the  cervix  is  examined,  the  vaginal  portion 
is  looked  at  first,  in  order  to  ascertain  whether  the  squamous  epithelium 
shows  the  proper  number  of  layers,  if  its  cells  present  the  usual  appearance, 
and  if  there  is  any  tendency  to  invasion  of  the  underlying  tissues.  Also,  if 
there  is  any  small  round-celled  or  polymorpho-nuclear  infiltration  between 
the  individual  cells.  An  increased  richness  in  the  blood  supply  is  also  to 
be  noted.  In  examining  the  cervical  portion  of  the  specimen  the  exact 
point  where  the  squamous  epithelium  ends  and  the  cylindrical  begins  must 
be  observed,  any  irregularity  of  the  surface  occasioned  by  the  mucosa  being 
gathered  up  into  small  polypi  should  be  observed;  the  shape  of  the  polypi, 
if  present ;  the  character  of  their  lining,  whether  one  layer  of  epithelium 
or  more ;  the  uniformity  or  irregularity  of  the  individual  cells,  and  their 
tendency  to  invade  surrounding  tissue;  and,  finally,  the  condition  of  the 
stroma. 

When  we  find  a  small  round-celled  infiltration  of  the  stroma 
between  the  individual  cells,  increased  richness  in  the  blood  supply, 
a  tendency  on  the  part  of  the  epitheliiun  to  gather  up  into  finger-like 
projections,  or  in  the  cervical  portion  any  change  in  the  shape 
of  the  glands,  and  any  proliferation  of  their  epithelial  lining, 
there  is  good  reason  to  suspect  a  carcinoma  and  the  specimen  should  be  further 
carefully  studied  for  evidences  of  new  gland  formation  and  invasion 
of   the   underlying   tissues. 

In  examining  the  uterine  mucosa  from  the  body  of  the  uterus,  it  must  be 
remembered  that  under  normal  conditions  a  teaspoonful  of  scrapings  is  all 
that  can  be  obtained,  and  the  presence  of  more  should  arouse  suspicion. 
ISTormally,  the  mucosa  comes  off  in  long  ribbons  about  two  or  three  millimetres 
broad  and  one  to  one  and  a  half  millimetres  thick,  but  where  malignant 
disease  is  present,  the  scrapings  are  usually  large,  irregular,  or 
cuboid  masses  about  one  centimetre  in  diameter.  The  tissue  is 
friable,  and  on  careful  teasing  it  is  often  possible  to  make  out  a  thread- 
like branching  appearance  on  the  surface.  Masses  of  tissue  are  also  found 
in  retained  secundines,  polypoid  and  ulcerative  endometritis,  and  necrotic 
myomata. 

Histologically,  the  character  of  the  mucosa  must  be  studied  in  order 
to  observe  whether  it  is  smooth  or  gathered  up  into  polypi,  or  papillary  or 
tree-like  growths,  etc.  Its  relative  thickness  and  the  character  of  the  surface 
epithelium  must  be  noted ;  also  the  shape  of  the  glands  on  cross-section,  as  to 
whether  they  are  round,  convoluted,  or  branching;  whether  they  are  uniformly 
distributed  or  lie  closely  together ;  whether  the  gland  epithelium  forms  one  or 
several  layers ;  and  whether  the  individual  cells  present  a  normal  appearance. 
The  glands,  if  there  are  any,  must  be  noted.  In  examining  the  stroma  the 
points  to  be  considered  are :  whether  it  is  dense  or  rarefied ;  the  character  of 


528 


CAlSrCEE    OF    THE    UTERUS. 


^^^^^^^^^^S 


the  stroma  cells ;  the  presence  of  any  small  round-celled  or  polymorplio-nuclear 

infiltration;  the  character  of  the  blood  vessels. 

If  the  surface  of  the  mucosa  is  gathered  into  folds  or  papillae  ; 

if  the   surface   epithelium   has    proliferated   so  as  to  be  more  than  one 

layer  in  thickness;  if  the    individual    epithelial    cells    are    swollen; 

if   they   contain    an   increased    amount    of    chromatin ;    if    the    glands 

are  increased  in  number  ;  if 
^^  they  are  markedly  convoluted 
and  bunched  together  ;  if  they 
are  much  branched  ;  if  they 
are  irregularlv  distributed 
throughout  the  stroma ;  if  the 
gland  cavity  is  partly  or 
completely  filled  with  epi- 
thelial cells  ;  if  the  stroma 
is  of  increased  density;  if 
the  stroma  cells  are  swollen  ; 
if  there  is  much  small  round- 
celled  or  p  o  1  y  m  o  r  p  h  o  -  n  u  - 
clear  infiltration  of  the 
stroma  ;  and  if  the  blood  sup- 
ply is  much  increased,  a 
diagnosis  of  cancer  of  the 
fundus  may  be  made  (see  Figs. 
14-i  and  l-i5). 

An  emphatic  word  of  cau- 
tion must  here  be  entered  against 
careless  manipulation  of 
scrapings  removed  for  mi- 
croscopic examination.  The 
specimens  must  be  clearly  labelled 
as  soon  as  removed  with  date, 
name,  operation,  destination,  and 
when  the  examination  is  made  no 
other  specimens  should  be  left 
lying  about  open  upon  the  same 
table.  If  the  slightest  doubt 
exists  in  regard  to  the  identity 
of     a     specimen     it    is    better    to 

throw  it   away,   even  though  it  is  necessary  to  curette   again  to  correct  the 

error. 


jV  J3  e  i.  £^e  3- j9(r 


Fig.  144. — Normal  Endometrium  from  a  Patient 
Thirty-three  Years  of  Age.  (80  diameters.) 
J.  H.  H.  Gyn.-Path.  No.  704.  The  surface  is  even, 
the  epitheUal  covering  well  preserved.  Two  glands 
are  ^^sible  opening  on  the  surface.  In  the  super- 
ficial portion  the  glands  are  few  in  number  and  are 
round  on  cross-section,  but  in  the  neighborhood  of 
the  muscle  thej^  are  cut  obliquely  and  are  slightly 
dilated.  The  gland  epithelium  is  e-verywhere  in- 
tact. The  stroma  is  uniform  in  density  and  con- 
sists of  cells  with  oval  vesicular  nuclei.  Most  of 
the  spindle-shaped  nuclei  seen  in  the  stroma  belong 
to  the  endothelium  of  the  capillaries,  b  indicates 
the  line  of  junction  between  the  mucosa  and  the 
muscle.  Sections  of  several  glands  are  visible  in 
the  muscle,  their  epithelium  being  unaltered  and 
the  glands  themselves  surrounded  by  the  stroma 
of  the  mucosa.  (From  T.  S.  Cullen,  "Cancer  of 
the  Uterus.") 


Fig.  145. — Adeno-carcinoma  of  the  Body  of  the  Uterus.  (130  diameters.)  J.  H.  H.  Gyn-Path. 
No.  324.  o,  May  be  compared  to  a  m.ain  stem,  from  which  arise  many  secondarj'  stemis,  which,  in 
turn,  give  off  delicate  terminals  consisting  entirely  of  epithelial  cells.  In  order  to  appreciate  the 
tree-like  arrangement  the  drawing  should  be  turned  upside  down.  The  glands  may  be  arbitrarily 
divided  into  groups,  a,  h,  c,  d,  and  e,  by  the  stems  of  stroma  /,  g,  and  h.  The  stems  are  covered  by 
several  layers  of  cylindrical  epithelium,  while  projecting  into  the  gland  cavities  are  long  slender  in- 
growths of  epithelium  devoid  of  stroma  as  seen  at  i.  Very  delicate  ingrowths  consisting  merely  of  two 
layers  of  epithelium  are  visible  at  k  and  k.  At  points  indicated  by  I,  the  epithelium  is  several  layers 
in  thickness.  At  vi  there  is  also  considerable  thickening  and  polymorphonuclear  leucocytes  are 
visible,  which  have  wandered  out  between  the  epithelial  cells.  At  n  numerous  polymorphonuclear 
leucocytes  are  seen  in  the  gland  cavities.  From  the  tree-like  arrangement  and  the  peculiar  gland- 
like grouping,  adeno-carciiaoma  may  be  readily  diagnosed.  (From  T.  S.  CuUen,  "Cancer  of  the 
Uterus.") 

35  529 


530 


CANCER    OF    THE    UTEEUS. 


PROPHYLAXIS. 


The  cancer  question  from  a  therapeutic  standpoint  has  a  threefold  aspect: 

(1)  the  discovery  of  the  cause  ;  (2)  the  effort  to  reach  the  cancer 
sufferers  at  an  earlier  stage  of  the  disease  while  it  is  still 
curable  ;  (3)  the  working  out  of  a  more  radical  operation.  The 
latter  condition  has  been  so  well  met  by  the  labors  of  J.  G.  Clark,  Sampson, 
Eiis,  Wertheim,  and  others,  that  it  seems  impossible  to  take  a  single  step  far- 
ther in  that  direction. 

The  working  out  of  the  cause  of  cancer  is  to-daj  a  question  of  laboratory 
investigation,  and  no  notable  progTCSs  is  as  yet  observable,  in  spite  of  countless 
investigations  by  an  army  of  skilled  workers,  and  in  spite  of  repeated  announce- 
ments proclaiming  the  great  discovery;  it  still  lies  in  the  womb  of  the  future, 
undemonstrated,  and  utterly  unknown. 

The  only  avenue  open  with  certainty  to  progress  to-day  lies  in  the  direc- 
tion of  discovering  our  cases  of  cancer  at  an  earlier  stage  in  the  disease,  and 
this  strategic  point  lies,  as  I  have  said,  almost  wholly  in  the  hands  of  the 
general  practitioners  of  our  land.  I  would  like  to  make  this  fact,  and 
the  consequences  which  flow  from  it,  the  point  of  greatest  im- 
portance which   I  wish  especially   to  emphasize   in  this   chapter. 

Can  we,  by  a  determined  attack  upon  this  point,  effect  any  appreciable 
change  in  the  present  deplorable  state  of  affairs  within  a  reasonable  period  of 
time,  say  five  or  ten  years  ?  This  question  is  best  answered  by  considering 
what  has  already  been  accomplished  on  these  lines  in  Germany. 

G.  Winter  of  Konigsburg  in  the  year  1902  undertook  to  improve  the  mor- 
tality statistics  of  cancer  of  the  uterus  in  the  only  way  open  to  him  at  that 
time  and  in  the  only  way  by  which  it  is  as  yet  possible  for  the  surgeon  to 
bring  about  an  immediate  improvement  in  his  ultimate  results,  namely,  by  a 
series  of  letters  addressed  to  physicians ;  by  a  series  of  articles  published  in 
the  medical  journals;  and  by  articles  appealing  directly  to  the  laity  and 
appearing  even  in  the  leading  daily  papers.  In  these  communications  he 
instructed  the  medical  profession  at  large  as  well  as  the  laity,  as  to  the  earliest 
signs  of  cancer,  and  as  well  as  the  supreme  importance  of  seeking  immediate 
relief  by  surgical  measures  when  these  signs  were  noted.  One  of  these  personal 
appeals  to  his  medical  brethren  was  a  brochure  entitled  "  The  Warfare  against 
Uterine  Cancer,  a  Word  to  All  Operators  for  Cancer,"  Stuttgart,  1904.  In 
the  CenfraJhlatt  fi'ir  Gyndlfologie,  1904,  vol.  28,  p.  441,  he  gives  a  resume  of 
the  results  of  this  interesting  propaganda,  w^here  he  insists  upon  the  following 
important  facts  with  which  every  physician  ought  now  to  be  familiar :  ( 1 )  Any 
immediate  improvement  in  the  final  results  of  operations  for  cancer  must 
depend  upon  the  performance  of  the  operation  at  the  earliest  possible  moment. 

(2)  It  is  possible  to  secure  patients  for  operation  regularly  within  four  weeks 
after  the  appearance  of  the  first  suspicious  symptom  and  it  is  well  worth  the 
effort.      (3)   The  chief  difficulties  in  the  way  of  the  operator,  and  the  cause 


PROPHYLAXIS.  531 

of  so  many  cases  applying  for  relief  too  late,  lie  in  the  fact  that  (a)  the  lay 
public  is  grossly  ignorant  of  the  possible  significance  of  the  early  symptoms 
of  cancer,  and  is,  therefore,  inclined  to  ignore  them  until  too  late,  and  (5)  the 
physicians  who  first  see  the  patients  fail  to  examine  them  promptly,  and  at 
the  first  visit,  as  they  ought  to  do.  A  few,  to  their  discredit  be  it  said, 
actually  seeing  an  early  cancer,  persist  in  treating  it  as  an  ulcer,  until  the 
favorable  period  has  passed  and  the  disease  has  advanced  too  far  for  radical 
treatment.  In  Germany  a  most  important  step  has  been  taken  in  seeing  that 
midwives  are  better  informed.  The  convincing  statistical  results  of  Winter's 
interesting  propaganda  are  as  follows: 

Out  of  eighty-four  women  who  applied  to  a  physician  after  the  issuance 
of  the  instructions,  only  five  were  not  immediately  examined — eleven  per  cent. 
This  contrasts  favorably  with  fourteen  and  two-tenths  per  cent  before  the  let- 
ters of  instructions  to  physicians. 

In  the  second  place,  in  response  to  his  invitation,  many  physicians  made 
use  of  the  facilities  of  Winter's  laboratory,  to  secure  a  microscopic  examina- 
tion of  tissues  in  suspected  cases.  Out  of  this  largely  increased  number  of 
specimens  sent  for  an  examination  and  an  opinion,  a  number  of  cancer  cases 
were  found.  As  Winter  remarks,  it  is  evident  from  this  that  the  seed  sown 
fell  on  fruitful  ground  in  the  consciences  of  the  physicians  addressed. 

Touching  the  midwives,  eight  cases  of  carcinoma  first  applied  to  them, 
and  only  one  entirely  neglected  her  duty  in  the  matter.  The  result  of  the 
appeal  to  the  midwives  through  the  instructions  was  almost  perfect.  As  to 
the  lay  public,  the  most  iiuportant  reasons  for  neglecting  the  early  symptoms 
of  cancer  are  ascribed  to  indolence,  ignorance,  false  modesty,  fear,  poverty, 
and  lack  of  time.  The  appeal  to  the  public  was  made  through  a  leading  daily 
paper,  in  an  article  entitled  "  The  Dangers  of  Cancer  in  the  Lower  Part  of 
the  Abdomen,  a  Word  of  Warning  to  Women,"  by  Prof.  Dr.  Winter,  of 
Ivonigsburg.  In  this  article,  giving  explicit  details,  he  shows  the  public  that 
most  cancer  cases  are  curable,  if  only  they  are  taken  in  time,  because  the  dis- 
ease begins  as  a  purely  local  affection.  He  further  makes  it  clear  that  an 
operation  is  the  only  possible  way  by  which  the  disease  can  be  cured,  a*nd  that 
the  responsibility  for  so  many  failures  lies  with  the  patient  who  comes  too  late 
to  be  helped,  a  delay  due  largely  to  her  ignorance  of  the  early  symptoms  of 
the  disease. 

That  cancer  is  frightfully  common  he  proves  by  a  reference  to  the  statistics 
of  East  Prussia  for  the  year.  He  also  urges  that  it  is  important  to  go  to  the 
right  place  to  secure  relief  immediately  upon  the  appearance  of  any  suspicious 
symptom. 

The  most  important  symptom  he  states  is  an  irregular  discharge  of  blood, 
particularly  among  women  of  a  more  advanced  age,  and  especially  in  those 
who  have  passed  the  menopause.  He  calls  special  attention  to  the  fact  that 
cancer  in  its  early  stages  does  not  cause  pain  and  therefore  its  absence  has  no 
significance. 


532  CANCER    OF    THE    TJTEEUS. 

As  a  result  of  these  instructions  he  found : 


189&-1902. 

1903. 

234  women. 

55  women. 

Within  the  first  month 

33  or  14  per  cent. 

43  or  18 

61  or  26 

28  or  12 

42  or  18 

27  or  12 

12  or  22  per  cent. 
19  or  35 

Waited  longer  than  1  month 

Waited  longer  than  ^  year 

18  or  33       " 

Waited  longer  than  ^  year 

3  or     5        " 

Waited  longer  than  f  year 

3  or     5        " 

Waited  longer  than  1  year 

0  or    0        " 

The  dwindling  percentages  in  the  right-hand  column  show  the  effect  of  the 
letter  of  instruction  upon  the  profession  as  well  as  upon  the  public.  ISTinety 
per  cent  of  the  patients,  after  the  instructions  had  been  issued,  applied  for 
operation  within  two  weeks  after  first  seeking  the  advice  of  a  physician.  The 
operability  of  the  cases  applying  to  him  increased  from  sixty-two  per  cent  before 
the  instructions  to  seventy-four  per  cent  afterwards. 

It  is  sufiiciently  evident  from  these  facts  that  a  warfare  against  uterine 
cancer,  carried  on  in  the  ranks  of  the  general  profession  and  also  among  the 
laity,  may  yield  extraordinary  results,  even  witliin  so  short  a  time  as  one  year. 

It  is  evident  also,  I  think,  that  if  we,  too,  here  in  America  would  make  any 
immediate  material  progress  in  dealing  with  the  cancer  problem  in  this  country, 
we  must  bravely  follow  Winter's  initiative,  however  distasteful  such  a  course 
of  publicity  may  be,  and  however  much  it  may  be  opposed  to  the  time-honored 
precedents  (shall  I  say  prejudices?)  of  the  medical  profession. 

I  further  urge  two  things  which  I  have  dwelt  upon  before,  namely : 

(1)  In  from  six  to  eight  weeks  after  every  confinement  the  medical  at- 
tendant should  see  his  patient,  with  the  object  of  making  a  careful  inspection 
and  of  noting  in  his  case-book  the  extent  of  the  traumatism  caused  by  the  labor 
and  just  what  lesions  remain. 

(2)  Every  woman  who  has  borne  children  should  be  examined  by  a  com- 
petent physician  at  least  once  every  year  until  she  is  fifty-five  years  old.  The 
effect  of  an  adoption  of  these  rules  would  be  prompt  discovery  of  an  enormous 
number  of  cancer  cases  in  their  very  incipiency.  That  such  a  course  w^ould  be 
distasteful  to  women  at  large,  I  do  not  doubt,  but  drastic  measures  are  often 
necessary  to  purge  ill  humors,  and  who  would  measure  such  a  trifling  sacrifice 
against  the  great  gain  of  even  a  small  increase  in  the  percentage  operability  of 
this  distressing  and  to-day  largely  hopeless  class  of  cases  ? 

TREATMENT. 

The  proper  treatment  for  cancer  whenever  it  is  possible  to  carry  it  out  with 
any  reasonable  hope  of  permanent  success  is  by  extirpation,  and  it  is  the  only 
one  which  affords  any  prospect  of  a  cure.  Every  case  is  operable  in  which  it  is 
possible  to  move  the  uterus  freely.     If  the  uterus  can  be  pushed  readily  up- 


CASES    FAVORABLE    FOE    OPERATIOF.  533 

wards  by  a  finger  resting  on  the  cervix,  it  has  lost  little  or  none  of  its  natural 
mobility,  and  in  cervical  cancer  this  fact  tends  to  show  that  the  disease  has 
not  extended  beyond  the  confines  of  the  cervix.  Every  such  case  should  be 
placed  in  the  hands  of  a  surgeon  who  has  had  considerable  experience  in  doing 
hysterectomy  for  cancer  within  a  week  after  the  physician  has  been  consulted; 
moreover,  the  surgeon  should  be  one  who  takes  a  hopeful  view  of  the  ultimate 
outcome  in  early  cases. 

The  hopeless  cases  are  those  in  which  the  uterus  is  fixed,  as  if  anchored,  by 
an  exudate  extending  from  the  cervix  uteri  out  to  the  pelvic  wall  on  one  or  both 
sides.  Even  in  such  cases,  however,  it  is  well  to  consult  a  specialist.  Let  the 
physician  note  well  that  the  cancerous  uterus  may  also  be  fixed  in  several  ways 
which  may  serve  to  confuse  his  diagnosis  when  he  tries  to  determine  the  oper- 
ability  of  a  given  case.  Coincident  pelvic  inflammatory  disea.se  may  so  fix  the 
uterus  that  it  seems  locked  fast  and  immovable.  A  big  pyometra  may  also 
fix  it.  Yet  neither  of  these  conditions  does  more  than  slightly  complicate  an 
operation  which  may  be  otherwise  easy.  If  the  cervix  is  stuffed  and  the  vaginal 
vault  choked  with  a  cauliflower  cancerous  mass,  this  may  interfere  with  mo- 
bility, but  when  the  mass  is  curetted  away,  the  uterus  becomes  quite  movable. 
Again,  I  repeat,  it  is  best  in  all  cases,  even  apparently  hopeless  ones,  to  see  the 
case  with  a  specialist  in  order  to  give  the  patient  the  benefit  of  his  judgment 
before  she  starts  down  that  long  sad  road  of  suffering,  humiliation,  and  ostra- 
cism to  the  gateway  over  which  is  written  nonquam  revertitur. 

If  the  cancerous  uterus  can  be  removed,  even  though  the  ultimate  success 
of  the  operation  in  eft'ecting  a  permanent  cure  is  doubtful,  it  ought  to  be  done, 
for  two  reasons:  In  the  first  place,  if  the  disease  returns,  it  is  often  in  a  less 
distressing  form,  characterized  by  the  absence  of  foul  discharges  and  hemor- 
rhages, and  that,  in  itself,  is  a  great  gain.  In  the  second  place,  a  case  which 
seems  hopeless  at  the  time  of  extirpation  may  run  for  years  without  a  recur- 
rence. I  know  of  several  instances  in  which  I  was  ready  to  give  a  hopeless 
prognosis  at  the  time  of  the  operation,  where  the  patient  has  remained  well  for 
a  number  of  years ;  in  one  it  was  my  confident  expectation  that .  the  disease 
would  return  almost  at  once,  and  yet  at  an  autopsy  made  ten  years  later  no 
cancer  was  discoverable. 

In  the  present  state  of  our  knowledge  upon  the  subject  there  are  many 
cases  which  do  not  com.e  into  the  physician's  hands  until  it  is  too  late  for 
operative  measures,  while  there  are  others  in  which  operation  is  only  tem- 
porarily successful,  the  disease  returning  after  a  longer  or  shorter  time.  In 
both  these  cases  the  question  of  palliative  treatment  becomes  of  great  importance, 
in  order  that  the  distressing  symptoms  associated  with  the  disease  may  receive 
as  much  alleviation  as  possible.  Lessening  of  the  foul  discharge  and  relief  of 
pain,  besides  buoying  up  the  sufferer's  spirits  in  the  thought  that  something  is 
being  done  for  her  relief,  are  of  immense  benefit  in  making  life  bearable  to  her 
in  the  last  stages  of  so  dreadful  a  malady.  Because  cancer  in  an  advanced 
stage  is  an  incurable  disease,  there  is  no  reason  why  the  physician  should  fold 


534 


CANCER    OF    THE    UTERUS. 


his  hands  and  saj  that  nothing  can  be  done.     It  is  just  as  much  his  duty  to 

relieve  suffering  as  to  effect  a  cure.  The 
various  means  of  relief  at  his  disposal 
are  here  discussed  seriatim. 

Curettage. — Even  far-advanced  cases 
where  there  is  marked  cachexia,  a  foul 
discharge,  nausea,  and  progressive  ema- 
ciation, are  often  much  benefited  by 
curettage,  by  means  of  which  the  masses 
of  diseased  tissue  are  removed  and  a 
clean  cone-shaped  excavation  remains  be- 
hind. The  severe  pain,  so  often  present 
in  advanced  cases,  is  frequently  due  to 
the  cervix  being  choked  with  retained 
discharges  resulting  in  the  formation  of 
a  pyometra  (see  Fig.  146),  and  the  evac- 
uation of  this  fluid  will  be  followed  by 
complete  relief  if  the  cervix  is  kept  open. 
It  is  remarkable  how  much  improvement 

Fig.  146. — Advanced  Stage  of  CEmrrcAL  Can-     will   foUow   SUch   a  thorough  curettage   or 
CER  Completely  Occluding  THE  Cervical       -,  .  p  r^^ 

Canal  WITH  FORMATION  OF  Pyoxmetra.  the  evacuation  01  a  pyometra.      I  he  pa- 


FiG.  147. — Showing  Patient  in  the  Perineal  Posture  on  a  Kelly  Pad  with  Posterior  and  Lat- 
eral Retractors  in  Place.  The  cancerous  cervix  is  by  this  means  brought  into  view  and  is 
ready  for  curettage. 


CURETTAGE    OF    UTERUS. 


535 


tient's  color  returns,  her  appetite  improves,  slie  ceases  for  a  time  to  lose  flesh, 
and  is  able  to  enjoy  life  while  the  improvement  lasts.  The  curettage  may  be 
repeated  four  or  five  times  during  the  course  of  the  disease. 

The  parts  are  exposed  as  shown  in  Figure  14Y,  after  which  the  friable 
and  most  redundant  portions  of  the  diseased  tissue  are  best  removed  by  the 
aid   of  the  index  and  middle  fingers,   and  it  is   aston- 
ishing how  much  tissue  can  be  taken  off  in  this  way. 
The  sharp,  serrated  spoon  curette   (see  Eig.  148,  or  the 
loop  curette,  Fig.   149)   is  then  used,  being  held  firmly 
and  moved  rapidly   and  boldly  as  it  breaks  down  the 
diseased  tissues  under  the  guidance 
of   the    index   finger,   which   locates 
the  points  to  be   curetted   and  also 
prevents    the    instrument    from    ad- 
vancing too  far  in  the  direction  of 
the  bladder,  the  rectum,  or  the  peri- 
toneal   cavity.      The    limit    of    dis- 
eased tissue  which  can  be  removed 
in   this   way    is   recognized   by    the 
scraping  sound  and  sensation,  indi- 
cating  that   a    firm    hard   base   has 
been  reached.     Less  blood  is  lost  by 
working   rapidly   down  to   healthier 
tissue  than  by    a   slower   procedure 
which  allows  the  rigid,  diseased  ves- 
sels to  bleed;  but  when  the  disease 
has  extended  so  far  that  the  oper- 
ator does  not  feel  sure  whether  the 
next  effort  will  not  invade  the  blad- 
der,   rectum,    or    peritoneum,    it    is 
important  to   advance  more   slowly, 
controlling  the  curettage  by  repeated 
examinations.      A  finger  in  the  rec- 
tum or  a  sound  in  the  bladder  will 
assist  in   determining  the  thickness 
of  the  septa. 

If  the  peritoneal  cavity  should  accidentally  be  opened,  an  iodoform  gauze 
tampon  must  at  once  be  packed  closely  within  the  rent  and  the  operation  con- 
tinued until  all  septic  and  sloughing  masses  have  been  removed,  down  to  a  clean 
wound  surface.  The  vagina  is  cleansed,  the  gauze  removed,  and  a  fresh  pack 
inserted,  which  enters  a  short  distance  into  the  pelvic  cavity.  This  is  allowed 
to  remain  in  place  for  three  or  four  days,  when  it  is  removed  and  a  fresh  one 
inserted.  The  excavated  area  and  the  vagina  must  be  loosely  filled  with  an 
iodoform  gauze  pack  and  protected  by  vulvar  occlusive  dressing. 


Fig.  148. — Spoon-shaped 
Curette  for  Use  in 
IIemoving  Tissue  from 
THE  Cancerous  Cervix. 


Fig.  149. — Open  T>oop 
Curette,  which  is 
Convenient  in  Some 

Cases. 


536  CANCEK.  OF  THE  UTERUS. 

Cauterization. — TTlien  tlie  bleeding  following  curettage  is  very  profuse,  it  is 
sometimes  necessary  to  cauterize  in  order  to  control  it ;  and  there  are  many 
cases  in  which  cauterization  is  desirable  for  its  ovna.  sake,  either  with  or  with- 
out curettage,  W.  B.  Chase  has  given  a  good  description  of  the  method  of 
using  the  actual  cautery,  which  I  quote  (Amer.  Jour.  Obst.,  1904:,  vol.  49,  p. 
83 :  "  Where  large  areas  of  ulceration  are  attacked  and  the  tissues  are  friable, 
the  curette  may  be  first  used  to  advantage.  This  is  likely  to  result  in  pretty 
active  hemorrhage.  The  hemorrhage  may  be  controlled  by  the  application  of 
pledgets  of  cotton  applied  with  pressure,  first  dipped  in  dilute  acetic  acid, 
usually  of  half  strength,  or  by  the  use  of  the  adrenalin  chloride.  After  this 
the  cautery  knife  is  apj)lied  at  a  dull  red  heat  imtil  the  surfaces  are  thoroughly 
charred.  The  after  dressing  consists  of  five  per  cent  iodoform  gauze,  reapplied 
daily  after  the  parts  have  been  cleaned  with  peroxide  of  hydrogen.  In  all 
manipulations  of  the  cervix  the  gTeatest  gentleness  should  be  used.  The  use 
of  bivalve  specula  should  be  avoided,  as  they  are  likely  to  impinge  upon  the 
cervix  and  occasion  hemorrhage.  Dressing  is  best  done  with  the  patient  in  the 
Sims'  position,  and  the  parts  exposed  by  means  of  a  Sims'  speculum.  The 
only  exception  is  when  the  posterior  vaginal  wall  is  involved.  The  slough 
separates  usually  in  from  one  to  two  weeks.  Daily  dressing  must  be  faithfully 
applied  every  day  until  healing  follows,  or,  if  it  should  not  ensue,  the  dress- 
ings must  be  continued  in  order  to  keep  the  parts  as  aseptic  as  possible." 

When  healing  is  imperfect  and  unhealthy  granulations  reappear,  they  may 
be  touched  with  carbolic  acid  or  nitrate  of  silver,  pure  or  diluted 
as  the  case  may  indicate.  After  the  first  day  or  two  the  parts  should  be 
douched,  when  the  gauze  is  removed  by  a  solution  of  lysol  (one  drachm  to 
a  quart  of  normal  salt  solution),  or  the  same  amount  of  a  fifteen-volume 
formalin,  one  drachm  to  a  quart,  or  a  weak  solution  of  tincture  of 
iodine. 

A  certain  skill  is  required  in  the  use  of  the  thermo-cautery.  The  cautery 
knife  must  be  of  just  the  right  temperature ;  that  is  to  say,  hot  enough  to  burn 
the  structures  and  not  hot  enough  to  disintegTate  them  too  rapidly,  which  causes 
trouble  and  hemorrhage.  Great  care  must  be  taken  to  avoid  going  beyond  the 
area  involved  and  injuring  the  bladder,  the  ureters,  the  rectum,  or  the  intestine. 
jSTo  pain  is  experienced,  as  a  rule,  from  the  use  of  the  actual  cautery,  provided 
the  cutaneous  surfaces  are  untouched;  on  the  contrary,  nothing  so  effectually 
relieves  the  pain  caused  by  the  disease  as  the  actual  cautery.  The  vaginal 
surfaces  may  be  protected  from  injurious  heat  by  using  strips  of  asbestos  paper 
of  proper  size  and  shape. 

The  choice  between  a  portable  galvano  and  a  Paquelin  cautery  is  largely 
a  matter  of  circumstances  and  convenience.  The  liability  of  most  galvano- 
cautery  batteries  to  get  out  of  order  is  an  objection,  and  it  is  never  safe  to 
begin  a  thermo-cautery  operation  without  a  second  apparatus,  either  galvanic 
or  Paquelin,  in  reserve.  In  some  cases  the  cauterization  may  have  to  be 
repeated  at  intervals  of  two,  three,  or  six  months. 


PALLIATIVE    TREATMENT.  537 

X-Ray. — H.  K.  Pancoast,  official  skiagrapher  of  tlie  University  of  Pennsyl- 
vania Hospital,  expresses  the  following  opinion  as  to  the  results  of  X-ray 
treatment  of  uterine  cancer  (Kelly-Noble,  "  Gynecological  and  Abdominal 
Surgery,"  1907,  vol.  1,  p.  321)  :  "  The  X-ray  may  prolong  the  life  of  the 
patient.  This  is  a  fact  worthy  of  recognition  in  many  instances.  The  relief  of 
pain  has  been  observed  by  reliable  authorities,  and  so  frequently,  too,  that  it 
must  be  recognized  as  a  commendable  result  due  directly  to  the  treatment,  and 
not  to  psychic  effect.  Pain  is  relieved  in  a  large  percentage  of  cases.  This  prob- 
ably results  largely  from  the  direct  anodyne  effects  of  the  rays.  When  the  pain 
is  due  to  presence  of  a  mass  upon  the  large  nerve  trunks,  little  relief  can  be  ex- 
pected. A  lessening  of  the  discharge  and  a  decrease  or  a  cessation  of  hemorrhage 
are  frequently  among  the  favorable  results,  and  are  often  brought  about  early." 
It  seems,  therefore,  that  when  it  is  possible  to  bring  the  patient  under  the  care  of 
a  reliable  radiograjDher  and  the  expense  of  the  treatment  is  within  her  means,  it 
is  worth  while  to  test  its  efficacy  in  any  given  case.  Unless  a  really  reliable 
X-ray  operator  is  at  hand,  however,  it  had  better  not  be  attempted,  as  the  care- 
less or  unskilful  use  of  the  method  has  produced  the  most  disastrous  results. 

Radium. — The  salts  of  radium  used  in  pencils  containing  not  less  than  15 
and  preferably  from  30-50  milligrams,  are  valuable  adjuncts  in  treating  some 
cases  of  malignant  diseases  of  the  pelvic  organs. 

First  of  all,  let  it  be  noted  that  radium  is  not  a  substitute  for  surgery,  its 
use  here  is  supplementary  to  the  surgical  operation.  But  it  does  do  what 
surgery  cannot  possibly  accomplish.  Its  field  of  greatest  usefulness  in  cancer 
of  the  cervix  is  after  extirpation.  Here  we  have  to  note  two  classes  of  cases : 
First  those  in  which  it  is  manifestly  impossible  to  extirpate  the  disease,  and  here 
the  radium  is  used  to  effect  those  more  distant  operations  inaccessible  to  the 
knife.  I  have,  for  example,  opened  the  abdomen  and  literally  carved  a  large 
cancerous  uterus  out  of  its  widely  impeded  bed  and  then  given  several  weeks 
of  all  night  treatments  with  an  average  dose  of  32  milligrams.  The  effect  of 
this  was  to  cause  a  remarkable  shrinkage  in  the  hardened  diseased  tissues  and 
a  manifest  improvement  in  the  patient's  condition;  relief  of  pain  and  cessation 
of  hemorrhage  and  for  a  time  apparently  complete  cure.  But  I  have  not 
yet  seen  an  advanced  case  of  this  kind  which  did  not  later  recur.  Wickham, 
however,  has  reported  two  such  cases. 

Secondly,  radium  is  of  the  utmost  value  in  treating  recurrences  at  the 
vaginal  vault.  I  had  a  case  which  recurred  in  the  right  vault  about  a  year  after 
operation,  the  disease  extended  like  a  finger  back  to  the  posterior  pelvis.  I 
thrust  the  radium  pencil  into  it  for  twenty-four  hours  on  three  occasions  and  she 
recovered  perfectly  with  no  recurrence  in  two  years. 

Another  use  for  radium  is  in  cancer  and  other  tumors  of  the  bladder.  I  have 
at  present  under  my  care  a  woman  sent  to  me  by  Dr.  Guy  L.  Hunner,  with  an 
inoperable  bladder,  carcinoma  projecting  far  out  into  the  organ,  fixed  and  occu- 
pying the  whole  left  wall,  edematous  and  looking  like  a  cockscomb.  This  has 
disappeared  under  treatments,  until  in  place  of  the  redundant  fungating  masses 


538  CANCER    OF    THE    TJTEETJS. 

we  have  an  ulcerated  surface  with  remarkable  general  improvement  and  sup- 
pression of  the  immense  hemorrhages  filling  the  bladder  with  clots  and  causing 
previously  uncontrollable  agonizing  pain. 

This  whole  subject  is  still  new,  but  we  are  undoubtedly  on  solid  ground  and 
each  year  will  add  to  our  acquisitions. 

Methylene  Blue. — The  treatment  of  cancer  by  methylene  blue  was  first  intro- 
duced in  1891  by  Professor  Mosetig-Moorhof,  who  read  a  paper  before  the 
Vienna  Society  of  Physicians ;  and  almost  at  the  same  time  one  appeared  by 
two  Italians,  Cucca  and  Ungaro  (Rassegna  d'ost,  e  gin,  1891,  vol,  26,  p.  598). 
The  first  person  to  advocate  the  use  of  the  method  in  this  country  was  Willy 
Meyer  {N.  Y.  Med.  Jour.,  April  11,  1891),  and  its  application  to  uterine 
cancer,  either  of  the  body  or  the  cervix,  has  been  especially  investigated  by 
H.  J.  Boldt  {Merck's  Bull.,  Jan.,  1893). 

The  cancerous  tissue  is  first  thoroughly  curetted  with  the  sharp  curette  and 
the  bleeding  surface  tamponed  with  dry  iodoform  gauze.  Twenty-four  to  forty- 
eight  hours  later  the  gauze  is  removed,  and  after  proper  disinfection  of  the 
field  of  operation  the  methylene  blue  is  injected.  The  patient  is  placed  in  the 
Sims'  position  and  the  surface  exposed  to  view  by  means  of  a  Sims'  speculum 
and  a  Hunter's  depressor.  The  parts  are  thoroughly  dried  with  aseptic  ab- 
sorbent cotton  and  the  needle  is  introduced  to  the  fundus  uteri,  the 
syringe  having  been  filled  with  an  aqueous  solution  of  blue  (pyoktanin),  1 :  100. 
The  needle  is  inserted  any  distance  from  half  a  centimetre  (one-fifth  of  an  inch) 
up  to  its  full  leng-th,  according  to  circumstances.  The  depth  to  which  it  is 
introduced  is  governed  by  the  thickness  of  the  part  where  the  injection  is  made. 
While  pushing  the  needle  still  deeper,  the  fluid  is  gradually  pressed  out  by  the 
piston  so  that  the  deeper  tissues  are  infiltrated  by  fresh  staining  fluid.  One 
syringeful  will  answer  for  two  or  three  punctures.  The  fluid  is  next  injected 
into  the  parametria  on  both  sides,  then  into  the  posterior  vaginal  wall, 
and  lasth-  into  the  anterior  infiltrated  vaginal  wall,  sometimes  mak- 
ing as  many  as  fifteen "  punctures  at  one  treatment.  It  is  best  to  begin  with 
the  most  distant  point,  because  on  withdrawal  of  the  needle  some  of  the  fluid 
returns  through  the  needle  puncture  and  discolors  the  tissues  adjoining,  a  thing 
which  would  interfere  with  the  requisite  amount  of  precision  for  succeeding 
injections  did  it  occur  more  proximally.  A  large  cotton  tampon  is  introduced 
into  the  vagina  in  front  of  the  cervix  and  some  protection  must  be  worn,  for 
even  with  the  greatest  care  the  clothing  is  apt  to  become  stained.  On  the  second 
day  after  the  injection,  the  patient  removes  the  tampon  by  means  of  the  string 
attached  to  it,  and  uses  a  douche  of  warm  water,  after  which  she  returns  to 
the  doctor's  office  for  another  treatment.  The  injections  are  repeated  every 
second  day  for  some  little  time. 

Methylene  blue  has  been  given  by  the  mouth  in  cases  where  the 
emplo^mient  of  injections  was  difficult  or  impossible,  and  has  been  strongly 
recommended  by  Dr.  Abraham  Jacobi  {Jour.  Amer.  Med.  Assoc.,  1906,  vol. 
47,  p.  1515).     Dr.  Jacobi  claims  that  this  method  of  administration  is  prefer- 


PAI.LIATIVE    TREATMENT  539 

able  to  local  injections,  because  the  latter  are  very  painful  and  patients  are 
unwilling  to  submit  to  them  for  any  length  of  time.  He  has  used  the  internal 
method  of  administration  for  fourteen  or  fifteen  years  and  obtained  the  best 
results  from  it. 

The  drug  is  given  in  pill  form  in  doses  of  two  grains  a  day,  increasing 
slowly  up  to  three,  four,  or  six  grains.  Larger  doses  have  been  given,  but  in 
Dr.  Jacobi's  opinion,  they  are  not  required.  It  is  a  good  plan  to  have  each  pill 
made  up  with  the  extract  of  belladonna,  to  as  much  as  three-fourths  of 
a  grain  in  twenty-four  hours ;  but  if  the  dose  of  methylene  blue  is  increased, 
the  belladonna  must  not  exceed  the  original  amount.  Arsenious  acid,  one- 
fortieth  to  one-twentieth  of  a  grain;  strychnin,  one-sixtieth  to  one-fortieth 
of  a  grain;  or  nux  vomica,  one-half  to  two  grains,  may  also  be  combined 
with  the  methylene  blue.  Patients  should  be  warned  at  the  beginning  of  the 
treatment  that  the  urine  will  be  stained  blue  from  the  drug,  and  that  a  stain 
on  the  linen  cannot  be  removed.  It  is  sometimes  stated  that  methylene  blue 
internally  will  cause  dysuria,  but  in  Dr.  Jacobi's  experience  this  does  not  often 
happen.     He  believes  the  use  of  the  belladonna  prevents  this  effect. 

In  many  of  the  cases  reported,  the  methylene-blue  treatment  has  been 
effectual  in  relieving  pain,  in  improving  the  functions  of  the  affected  part,  and 
improvement  of  the  general  condition.  Moreover,  it  is  claimed  that  with  the 
steady  use  of  it,  it  is  possible  to  avoid  the  use  of  morphin  up  to  the  last  stages 
of  the  disease.  Locally,  there  is  a  more  healthy  appearance  of  ulcerating  sur- 
faces with  cicatrization  towards  the  edges ;  the  discharges  become  scanty  and 
less  offensive,  and  shrinkage  occurs  in  the  growth  itself. 

It  occasionally  happens  that  the  administration  of  the  drug,  whether  by 
injection  or  by  the  mouth,  is  followed  by  disagreeable  symptoms.  There  is 
nausea,  vomiting,  a  weak  slow  pulse,  headache,  and  general  malaise,  which 
appear,  as  a  rule,  on  the  day  of  injection  or  the  day  following.  Now 
and  then  there  is  a  slight  rise  of  temperature.  Locally,  there  is  sometimes 
edema  around  an  injected  area,  accompanied  by  slight  redness  and  pain  on 
pressure,  but  these  disturbances  disappear  quickly.  The  only  really  serious 
result  which  has  been  known  to  follow  the  use  of  the  remedy  is  the  formation 
of  sinuses  which  give  exit  to  a  dark  blue  fluid.  Sometimes  a  few  of  these 
softened  foci  join  and  form  a  swelling  containing  pus.  When  this  happens, 
the  abscess  must  be  opened,  not  by  the  customary  long  slit,  but  by  a  small 
puncture  just  sufficient  to  let  out  the  fluid.  This  accident,  however,  does  not 
occur  often  and  seems  to  be  associated  with  the  use  of  strong  solutions. 

The  injection  of  methylene  blue  into  the  uterus  requires  not  only  the  most 
rigid  antisepsis,  but  considerable  knowledge  of  surgery,  and  unless  the  physi- 
cian has  had  a  good  deal  of  surgical  experience,  it  is  best  for  him  to  administer 
the  drug  by  the  mouth.  Whichever  method  he  employs  let  him  make  sure  that 
the  preparation  of  the  drug  is  perfectly  pure  and  unadulterated. 

Thyroid  Extract. — The  treatment  of  inoperable  cases  of  cancer  by  means  of 
thyroid  extract  has  of  late  been  the  subject  of  discussion.     The  extract  may 


540  CAKCEE  OF  THE  UTEEUS. 

be  given  in  subst-ance  in  capsules,  or  the  fluid  extract  may  be  used.  The  dose 
varies  from  four  to  six  gTains  a  day  according  to  the  individual  susceptibility. 
In  primary  carcinoma  it  is  best  to  begin  with  large  doses,  but  in  the  recurrent 
form  small  ones  answer  better.  Some  physicians  are  of  opinion  that  the  remedy 
is  more  successful  in  secondary  carcinoma  than  in  the  primary  form. 

Trypsin. — The  use  of  trypsin  in  the  treatment  of  carcinoma  was  suggested 
by  Beard  of  Edinburgh,  whose  experiments  on  mice  afforded  the  hope  that  it 
might  be  of  gTeat  service.  Opinion  seems  still  to  be  divided,  however,  on  the 
question  of  the  beneficial  results  derived  from  it,  and  some  persons  have  re- 
ported considerable  harm  arising  from  it,  e.  g.,  "W.  A.  Pusey  {^Jour.  Am.  Med. 
Assoc,  1906,  vol.  16,  p.  1763). 

Acetone. — The  treatment  of  inoperable  carcinoma  by  means  of  acetone  is 
strongly  advocated  by  George  Gellhorn  {Jour.  Amer.  2Ied.  Assoc,  1907,  voL 
48,  p.  1100),  and  should  the  future  fulfil  the  present  promise,  there  is  no  doubt 
that  it  will  be  a  valuable  palliative  form  of  treatment.  Dr.  Gellhorn  experi- 
mented for  eighteen  months  with  different  chemicals  which  he  thought  might 
offer  some  improvement  in  the  existing  conditions  for  treatment  of  inoperable 
cancer,  and  finally  found  that  he  obtained  unexpectedly  good  results  with 
acetone,  in  regard  to  which  he  says :  "  In  the  limited  number  of  cases  in  which 
it  has  been  employed  it  seems  to  have  successfully  met  the  chief  requirements 
in  the  treatment  of  inoperable  cancer  of  the  uterus." 

Acetone  is  present  in  all  normal  urine  and  is  familiar  to  the  clinician 
from  its  occurrence  in  the  urine  in  diabetes  mellitus,  in  certain  forms  of  digest- 
ive disturbance,  and  in  some  cases  of  carcinoma.  It  is  a  transparent,  colorless, 
mobile,  and  volatile  liquid  with  a  characteristic  pungent  sweetish  taste  and  odor. 
If  applied  to  the  skin,  it  causes  a  sensation  of  cold.  Tissues  j)laced  in  it 
shrink  and  harden  rapid;ly  owing  to  its  intense  hygTOscopic  qualities, 
and  if  left  in  the  fluid  more  than  haK  an  hour  they  are,  as  a  rule,  too  hard 
for  the  microtome  knife.  It  was  Dr.  Gellhorn's  idea  to  utilize  these  hardening 
powers  for  practical  purposes.  If  the  ulcerating  surface  of  the  cancer  could 
be  hardened,  in  vivo,  the  discharge  could  be  checked  and  the  escharotic  portion 
would  be  cast  off.  The  resulting  free  surface  could  then  be  hardened,  and  it 
would,  perhaps,  be  j^ossible  to  harden  deeper  portions,  or  even  the  entire  tumor, 
thus  rendering  the  malignant  growth  temporarily  harmless. 

The  treatment  must,  if  possible,  be  preceded  by  a  thorough  curetting  of  the 
ulcerating  area.  The  curetted  cavity  is  then  carefully  dried  with  cotton 
sponges,  and  from  one-half  to  one  ounce  of  acetone  is  poured  into  it  through  a 
Ferguson  or  some  other  tubular  speculum.  The  narcosis  may  then  be  inter- 
rupted and  the  patient  left  in  the  same  position  from  fifteen  to  thirty  minutes. 
The  acetone  is  then  allowed  to  run  out  through  the  speculum  by  lowering  the 
pelvis,  and  the  cavity  is  packed  with  a  narrow  gauze  strip  soaked  in  acetone. 
The  healthy  mucosa  of  the  vagina  and  the  vulva  ai'e  cleansed  with  sterile  water 
and  dried.     After  the  preliminary  curetting  and  cauterization  the  regular  treat- 


PALLIATIVE    TREATMENT.  541 

ment  is  administered  two  or  three  times  a  week,  beginning  on  the  fourth  or 
fifth  day  after  the  operation. 

For  the  preliminary  treatment  the  patient  must,  of  conrse,  be  in  a  hospital 
or  in  her  own  house,  but  the  further  treatment  may  be  administered  in  the 
physician's  consulting  room.  It  is  done  without  an  anesthetic  and  may  be 
given  with  the  patient  on  the  ordinary  examining  table  or  chair.  The  pelvis 
of  the  patient  is  raised  and  the  tubular  sj)eculum  inserted  into  the  cancerous 
cavity;  it  is  then  filled  with  acetone,  and  may  be  held  in  place  by  the  patient's 
hand  for  half  an  hour,  after  which  it  is  emptied  in  the  manner  above  described. 
Care  must  be  taken  to  prevent  the  acetone  from  running  over  the  vulva  and 
the  perineum.  As  the  cancerous  area  diminishes,  smaller  and  smaller  specula 
can  be  employed. 

The  immediate  effect  of  the  treatment  is  to  check  any  slight  oozing  almost 
immediately.  The  surface  of  the  crater  is  covered  with  a  thin,  whitish  film, 
which  becomes  light  brown  wherever  there  is  an  extravasation  of  blood.  The 
normal  vagina  is  not  appreciably  irritated.  On  the  vulvar  mucosa  and  the 
outer  skin  an  excess  of  acetone  produces  a  faint  whitish  discoloration,  which 
soon  disappears.  Tliere  is  no  pain  from  the  cauterization,  although  a  slight 
stinging  sensation  may  be  experienced  if  the  acetone  has  touched  the  skin. 
This  passes  away  rapidly,  however,  if  the  affected  part  is  washed  with  cool 
water.  Anodynes  are  not  needed  after  the  treatment,  except  in  special  cases. 
One  of  the  most  distinct  beneficial  effects  is  a  marked  reduction  of  the  intense 
odor.  The  discharge  becomes  watery,  then  gradually  subsides,  and  with  it  dis- 
appears the  intense  and  disagreeable  odor  attending  it.  The  hemorrhages 
also  cease  to  recur,  and  after  two  or  three  weeks  of  treatment  a  considerable 
diminution  in  the  size  of  the  cavity  may  be  noticed.  Its  walls  become  smooth 
and  firm,  there  are  no  more  polypoid  excrescences,  nor  can  the  finger  remove 
any  friable  tissue. 

The  absence  of  hemorrhages  and  weakening  discharges  causes  a  great  im- 
provement in  the  general  condition  of  the  patient ;  on  the  other  hand,  sensations 
of  pain  caused  by  the  extension  of  the  cancer  to  adjoining  organs  or  nerve 
trunks  beyond  the  reach  of  the  acetone  are  not  relieved  and  require  the  use  of 
an  anodyne  as  before.  In  Gellhorn's  experiments  frequent  examinations  of  the 
urine  were  made,  in  order  to  ascertain  if  there  was  any  absorption  of  acetone 
into  the  organism,  but  they  were  all  negative. 

The  number  of  cases  upon  which  the  acetone  treatment  has  been  tried  is, 
so  far,  too  small  to  form  positive  conclusions;  the  results,  so  far  as  they  go,  are, 
nevertheless,  so  good  that  it  seems  reasonable  to  hope  that  a  valuable  palliative 
measure  for  inoperable  cases  has  been  found.  Even  though  the  pain  is  not 
affected  by  it,  the  relief  from  hemorrhage  and  from  the  characteristic  odor, 
which  is  one  of  the  most  distressing  features  of  the  disease,  recommends  the 
treatment  most  highly  to  our  notice.  The  ease  with  which  it  can  be  con- 
ducted by  the  general  practitioner,  and  the  absence  of  ill  effects,  add  greatly 
to  its  value. 


542  CANCER    OF    THE    UTEEITS. 

General  Eemedial  Measures. — In  all  cases  of  inoperaLle  cancer,  every  care 
must  be  taken  to  keep  the  patient's  general  condition  as  good  as 
possible.  Her  digestion  and  appetite  ninst  be  kept  np  by  appropriate 
measures,  and  she  must  have  as  much  fresh  air  as  possible.  In  the  use  of 
remedies  for  the  relief  of  pain  the  greatest  caution  must  be  exercised.  It  is 
sometimes  said  that  there  cannot  be  any  objection  to  the  unrestricted  use  of 
opium  v^hen  there  is  no  possibility  of  recovery,  but  it  must  be  remembered 
that,  unless  the  resources  of  opium  are  carefully  husbanded,  they  will  fail  be- 
fore the  close  of  life,  and  the  patient  will  be  left  with  no  protection  against 
suffering  at  the  time  when  it  is  most  intense.  Even  the  largest  doses  will  at 
last  prove  ineffectual.  It  is  best,  therefore,  to  avoid  the  use  of  opium  as  long 
as  possible,  and  when  this  can  no  longer  be  done,  it  must  be  given  carefully  by 
the  physician  or  the  nurse,  and  the  amount  modified  according  to  necessity. 

In  the  beginning  of  the  disease,  before  the  pain  has  become  intensely  severe, 
relief  may  be  obtained  from  the  coal-tar  preparations  such  as  phenacetin,  anti- 
pyrin,  and  others.  Aspirin,  the  acetic  ether  of  salicylic  acid,  has  been  highly 
spoken  of  in  this  connection,  especially  by  Ludwig  Goth  (Med.  Bldtt.,  Feb.  11, 
1904).  It  is  said  to  relieve  pain  very  quickly  and  without  disagreeable  after- 
effects. The  dose  is  one  gTamme  (fifteen  gTains)  daily.  If  this  dose  does  not 
give  relief  it  is  of  no  use  to  continue  it. 

Vaginal  injections  of  chloral  hydrate  in  strength  of  10:1000 
have  been  recommended  for  relief  of  pain  and  for  disinfection  of  the  vagina. 

Opium  is  best  administered  at  first  in  the  form  of  codein,  one-fourth  of  a 
grain,  increased  as  occasion  requires.  When  this  fails  it  will  be  necessary  to 
have  recourse  to  opium  itself,  which  generally  does  better  than  morphin.  It 
is  well  to  administer  it  at  first  disguised  in  some  stimulant,  such  as  wine  of 
coca.     The  patient,  ignorant  of  the  drug,  will  not  learn  to  depend  on  it. 

Hemorrhages,  when  they  occur,  are  best  controlled  by  douching  with  hot 
water  and  packing  with  gauze.  Vinegar  and  ice-water  have  been  recom- 
mended as  excellent  styptics.  Adrenalin  has  been  used  very  successfully  in 
the  hemorrhages  of  carcinoma.  Peters  (Zeitschr.  f.  Gyn.,  1904,  ISTo.  27) 
recommends  it  in  normal  salt  solution  of  1 :  2000  or  1 :  3000.  This  is  applied 
for  two  minutes  to  the  cavity  of  the  uterus. 

Throughout  the  illness  the  vagina  should  be  frequently  washed  out  with 
Labarraque's  solution  (see  Chap.  XIII,  p.  324)  as  a  disinfectant  and 
deodorant.     Creolin,  1:  500,  is  also  useful  for  this  purpose. 

It  is  of  great  importance  to  keep  the  surroundings  of  the  patient  cheerful. 
But  if  she  supposes  that  a  knowledge  of  her  real  condition  is  being  with- 
held from  her,  uncertainty  and  suspicion  may  react  most  unfavorably  on  her. 
If  she  asks  direct  questions  they  should  be  truthfully  answered,  and  if  she 
seems  to  be  fretting  in  silence  it  is  best  to  draw  out  exactly  what  are  the  ex- 
tent of  her  suspicions  and  deal  with  them  as  fully  as  seems  necessary  to  ensure 
her  peace  of  mind.  Her  family,  or  at  any  rate  some  responsible  member  of  it, 
should  be  fully  informed  of  the  nature  of  the  disease  and  its  progTess. 


CHAPTER    XXII. 

CYSTITIS. 

Definition,  p.  543.     Classification,  p.  543.     Etiology,  p.  544.     Symptoms,  p.  547.     Diagnosis, 

p.  548.     Treatment,  p.  544. 

DEFINITION. 

Cystitis  is  an  inflammation  of  the  bladder,  caused  by  micro- 
organisms; it  is  associated  with  the  discharge  of  pus  and  sometimes  of  blood 
in  the  act  of  urination,  which,  as  a  rule,  is  increased  in  frequency  and  painful. 
Cystitis  is,  therefore,  an  inflammatory  affection  and  must  be  distinguished  from 
simple  hyperemias,  such  as  are  often  found  in  the  trigonum  of  the  bladder 
and  present  many  appearances  of  inflammation,  but  without  any  evidences  of 
infection  and  without  pus  in  the  urine.  Cystitis  is  also  readily  distinguished 
from  the  frequent  urination  (pollakiuria)  often  noted  in  nervous 
patients,  or  in  those  whose  urine  contains  some  irritating  substance. 

CLASSIFICATION. 

There  are  different  kinds  of  cystitis,  and  it  may  be  classified  in  a  variety  of 
ways.  First,  according  to  the  intensity  of  the  disease.  In  some 
cases  it  is  so  mild  as  to  escape  the  attention  of  the  patient ;  in  others,  so  intense 
as  to  make  life  itself  a-  burden. 

Second,  into  acute  and  chronic  forms,  a  most  important  classifica- 
tion. The  acute  are  marked  by  suddenness  of  onset  and  intensity  of  symptoms, 
but  they  are  of  short  duration,  passing  soon  into  the  chronic  stage.  Most  cases 
develop  slowly  and  are  chronic  from  the  first. 

Third,  according  to  location.  The  patch  of  cystitis  may  be  seated 
in  the  vault  of  the  bladder,  in  the  posterior  wall,  or  at  the  base.  The  disease 
may  be  limited  to  one  of  these  foci,  or  it  may  spread  out  from  one  or  from  sev- 
eral of  them  until  the  entire  bladder  wall  has  an  angry,  beefy-red  appearance. 

Tourth,  according  to  the  character  of  the  infecting  organism.  By 
this  classification  we  have: 

Tubercular  cystitis. 

Gonorrheal  cystitis. 

Colon  bacillus  cystitis. 

Proteus  cystitis. 

Streptococcus  cystitis. 

Staphylococcus  cystitis. 

543 


544  CYSTITIS. 

Several  rarer  forms  of  more  interest  to  the  bacteriologist  than  to  the  prac- 
titioner. 

Fifth,  according  to  the  portal  of  infection.  When  the  bladder  is 
infected  by  organisms  carried  directly  to  it  by  the  blood,  the  infection  is 
primary  ;  and  when  the  organisms  proceed  from  a  focus  of  infection  in 
some  other  organ,  as  the  kidney  or  one  of  the  uterine  tubes,  it  is   secondary. 

Sixth,  according  to  the  direction  in  which  it  progresses.  Cystitis 
is  ascending  when  the  infection  is  introduced  from  below,  and  ascends  from 
the  urethra  upwards;  descending  when  it  is  introduced  above,  and  proceeds 
•from  the  kidney  downwards. 

A  latent  cystitis  is  not  infrequently  seen  in  surgical  patients,  examined 
as  a  matter  of  routine  for  urinary  infections  before  operation,  whether  they 
complain  of  any  bladder  symptoms  or  not.  This  group  of  cases  is  an  important 
one,  as  the  recognition  of  the  disease  before  operation  in  any  given  case  relieves 
the  surgeon  of  responsibility,  and  refutes  any  imputation  of  having  caused  the 
trouble  by  neglect,  in  the  event  of  an  exacerbation  during  convalescence. 

ETIOLOGY. 

The  commonest  source  of  cystitis  in  these  days  is  the  urinary  catheter, 
especially  when  emploj^ed  during  the  puerperal  period  or  after  surgical  opera- 
tions. Put  a  catheter  in  unskilled  hands,  and  cystitis  is  pretty  sure  to  follow 
its  use.  The  blame  for  lack  of  skill  may  fall  upon  the  shoulders  of  the  doctor, 
as  well  as  of  the  nurse,  the  latter  of  whom  is  too  often  made  a  scapegoat.  I 
know  of  an  instance  of  an  old  practitioner  who  catheterized  a  patient  in  hard 
labor,  introducing  the  catheter  several  times.  The  baby  was  born  dead  and  a 
number  of  curious  little  holes  were  found  punched  into  its  brains.  These  were 
produced  by  the  catheter,  which  had  been  forced  through  the  urethra  and  then 
through  the  baby's  skull.  An  unclean  catheter  will  cause  cystitis  in  the  vast 
majority  of  cases,  but  with  proper  attention  to  cleanliness  no  trouble  will  ordi- 
narily arise  from  its  use. 

The  reason  cystitis  so  often  dates  from  confinement,  and  especially  from 
repeated  catheterization  in  the  puerperal  period,  lies  in  the  fact  that  in  diffi- 
cult labor  the  bladder  is  always  more  or  less  injured,  the  resisting  powers  of 
the  patient  are  lowered,  and  the  lochia  bathing  the  external  genitals  and  the 
urethra  are  a  constant  source  of  infection.  Added  to  this  is  the  awkward  posi- 
tion of  the  patient  as  she  lies  in  bed  and  the  swollen  condition  of  the  vulva. 
A  catheter  introduced  under  such  circumstances,  even  if  considerable  care  is 
taken,  is  pretty  sure  to  convey  some  infection. 

The  cystitis  which  arises  after  an  operation  is  also  occasionally  unavoidable, 
even  with  the  best  skill  and  technic.  This  is  undoubtedly  due  to  the  reduced 
condition  of  the  patient,  who  has  passed  through  the  shock  of  an  operation  and 
whose  reparative  processes  are  consequently  much  below  par.  Under  these  cir- 
cumstances she  is  unable  to  resist  an  infection  which  would  be  easily  thrown 


ETIOLOGY.  545 

off  under  normal  conditions.  The  attending  circumstances  of  pelvic  operations 
are  frequently  so  damaging  to  the  bladder  that  the  wonder  is,  not  that  we  have 
cystitis,  but  that  it  does  not  develop  oftener.  Take,  for  example,  a  hystero- 
myomectomy  or  an  abdominal  hysterectomy  for  carcinoma,  and  we  have  to  do 
with  patients  under  conditions  most  favorable  for  the  development  of  cystitis, 
as  follows : 

(1)  A  depressed  state  of  health  before  operation. 

(2)  Often  a  condition  of  severe  mental  depression. 

(3)  A  severe  mutilating  operation. 

(4)  Severe  trauma  exercised  upon  the  bladder  itself. 

(5)  In  some  cases,  protraction  of  the  operation  which  taxes  the  vital  forces 
to  their  utmost. 

(6)  Considerable,  sometimes  excessive  loss  of  blood. 

(7)  In  the  case  of  carcinoma,  injury  of  the  bladder  at  the  point  of  detach- 
ment from  the  uterus  and  the  vagina,  an  injury  which  must  heal  by  suppura- 
tion during  convalescence. 

(8)  Constraint  of  posture  after  operation,  when  the  patient  lies  on  her  back 
and  is  unable  to  empty  her  bladder  properly  on  account  of  the  unusual  position, 
so  that  there  is  either  an  overdistention  or  a  residuum  of  urine  after  voiding. 

(9)  Complications  during  convalescence  causing  elevation  of  temperature, 
which  further  lowers  resistance. 

With  all  these  favoring  conditions  it  is  not  remarkable,  as  I  have  said  be- 
fore, that  cystitis  is  a  common  complication  of  the  convalescence  in  pelvic 
surgical  cases.  The  reason  for  the  frequency  of  cystitis  in  those  cases  which 
have  to  be  catheterized  repeatedly,  is  found  in  the  fact  that  the  external 
urethra  and  the  parts  of  the  urinary  canal  adjacent  to  the  external  orifice 
are  normally  the  habitat  of  a  profuse  bacterial  flora,  especially  the  colon 
bacillus. 

The  history  of  a  patient  suffering  from  cystitis  often  throws  great  light 
upon  the  case.  In  young  women  and  unmarried  women,  where  the  disease  is 
seen  in  an  aggravated  form  and  there  is  a  history  of  suffering  of  years'  stand- 
ing, where  the  urine  is  cloudy,  and  there  is  a  continual  desire  for  urination 
night  and  day,  the  disease  is  apt  to  be  tubercular,  and  to  arise  from  a  tuber- 
cular infection  of  one  or,  it  may  be,  both  kidneys.  Often  there  is  no  complaint 
whatever  of  any  discomfort  in  the  loin,  even  with  an  aggravated  disease  in  the 
kidney.  These  cases  are  frequently  mistaken  for  primary  vesical  tuberculosis, 
whereas  a  primary  tuberculosis  of  the  bladder  is  one  of  the  rarest  of  urinary 
affections.  In  women,  a  vesical  tuberculosis  is  almost  always  descending  from 
the  kidney;  while  in  men,  it  may  be  ascending  from  the  genital  organs  or 
descending  through  the  ureters. 

Again,  a  patient,  a  married  woman,  may  state  that  she  dates  all  her  vesical 
difficulties  from  a  confinement,  when  it  was  necessary  to  catheterize  her  fre- 
quently. Cases  of  this  kind  are,  as  a  rule,  colon  bacillus  infections.  Some- 
times the  patient  blames  a  physician  or  a  nurse  unjustly,  in  response  to  the 
36 


546  CYSTITIS. 

desire  natural  to  human  nature  to  find  fault  with  some  other  person  when 
anything  goes  wrong. 

In  taking  a  history,  the  actual  present  condition  should  first  be  inquired  into 
as  follows : 

How  often  the  patient  urinates  ? 

How  frequently  at  night  ? 

How  much  j)ain  in  the  act  ? 

When  the  pain  is  most  intense  ? 

How  long  the  pain  lasts  ? 

Is  it  possible  to  control  the  bladder  when  the  desire  for  urination  occurs  ? 

Is  the  trouble  tending  to  get  better  or  worse? 

Is  it  affected  by  menstruation  ? 

Is  it  worse  when  the  bowels  move  ? 

When  these  points  are  settled  it  is  best  to  go  back  in  the  history  and  ask : 

How  and  when  did  the  urinary  difficulty  begin  ? 

When  was  the  patient  last  perfectly  well  ? 

Does  the  trouble  date  from  any  particular  event,  such  as  a  confinement  or 
an  operation  ? 

Is  it  attributable  to  catching  cold? 

Did  it  begin  in  a  severe  form,  or  with  a  slight  distress,  increasing  fre- 
quency of  urination,  and  pain? 

Did  it,  perhaps,  begin  with  frequency  of  urination  without  any  pain  at  all  ? 

What  treatment,  if  any,  has  been  tried  up  to  the  time  of  inquiry? 

I  give  here  two  typical  histories,  one  in  which  the  pain  began  sharply  and 
the  cystitis  is  referred  to  a  particular  event;  another  where  the  cystitis  came 
on  gTadually,  from  no  known  cause. 

Case  L— Mrs.  A.  L.  M.,  age  forty,  April,  1907  (San.  Xo.  2421).  This 
patient  complained  of  a  bloody  discharge,  which  proved  to  be  due  to  cancer  of 
the  cervix  uteri.  Her  family  history  was  negative,  she  had  always  had  good 
health,  and  was  the  mother  of  four  children.  Up  to  the  time  of  her  admission 
to  my  private  hospital  she  had  never  had  any  bladder  or  kidney  trouble,  and 
the  urinary  examination  showed  clear  urine,  a  specific  gTavity  of  1.018,  acid 
reaction,  no  sugar,  no  albumen,  and  no  abnormal  microscopical  elements. 
The  cervical  cancer  was  favorable  for  operation,  as  it  was  still  limited  to  the 
uterus.  An  abdominal  pan-hysterectomy,  after  the  method  of  Wertheim,  was 
performed.  Subsesquent  to  operation  the  patient  had  to  be  catheterized,  and 
three  days  later  she  began  to  have  intense  burning  pain  in  the  bladder  with  a 
great  desire  to  void  urine.  The  pain  was  excruciating.  Examination  of  the 
urine  showed  abundant  pus,  some  red  blood  cells,  considerable  bladder  epi- 
thelium, and  a  pure  culture  of  the  colon  bacillus.  The  patient  was  at  once 
put  on  urotropin,  fifteen  grains  three  times  daily,  and  was  given  all  the 
water  she  could  drink.  In  addition  to  these  remedies,  the  bladder  was  irrigated 
daily  with  a  solution  of  boracic   acid.    After  the  first  few  days  the  pain  and 


SYMPTOMS.  547 

discomfort  ceased,  but  for  a  month  there  continued  to  he  some  pus  cells  present 
in  the  urine  and  some  bacteria,  and  it  was  not  until  nearly  six  weeks  after  the 
operation  that  the  urine  was  perfectly  normal.  The  patient  was  discharged  a 
few  days  later,  and  went  home  cured  of  her  cancer  and  relieved  of  her  cystitis. 

Case  II. — Miss  E.  E.,  age  twenty-seven,  May,  1907  (San.  :^o.  2443). 
This  patient  complained  of  pain  and  frequency  of  urination.  Her  family  his- 
tory was  entirely  negative  as  to  bladder  disease  or  nervous  ailments.  Her 
health  had  never  been  strong,  though  appetite  and  digestion  were  always  good. 
Menstruation  had  been  always  regular,  painless,  and  in  every  way  normal. 
The  bladder  trouble  had  begun  insidiously  three  years  before.  At  first  there 
was  nothing  more  than  a  slight  increase  in  the  frequency  of  urination,  but  this 
increased  gradually  and  became  associated  with  pain.  The  condition  continued 
to  develop  in  spite  of  local  treatment  carried  out  by  her  physician,  until  the 
patient  had  lost  much  flesh  and  was  in  a  great  deal  of  pain.  The  urine,  exam- 
ined on  the  day  of  her  admission  to  my  private  hospital,  was  of  normal  acidity, 
with  a  specific  gravity  of  1.030 ;  it  contained  no  pus,  no  blood,  no  casts,  and  no 
bacteria.  Examination  of  the  bladder  showed  it  to  be  of  normal  size  with 
about  four  hundred  cubic  centimetres'  capacity.  Its  appearance  was  normal 
everywhere  except  for  an  area  of  reddening  and  ulceration  in  the  vertex, 
lying  in  a  transverse  direction.  This  was  about  four  centimetres  long  by  one 
wide.  The  ureteral  orifices  were  perfectly  normal  and  secreting  actively.  An 
attempt  was  made  to  treat  this  patient  by  local  applications  and  by  irrigations, 
but  the  treatment  caused  such  intense  pain  that  it  had  to  be  abandoned.  I 
then  made  a  suprapubic  opening  into  the  bladder  and  excised  the  ulcer  as  well 
as  another  small  piece  of  the  bladder,  which  was  reddened.  The  wounds  in  the 
bladder  were  sewed  up  with  catgut  and  the  suprapubic  opening  closed  with  it. 
The  healing  was  prompt  and  the  relief  almost  immediate..  The  second  exam- 
ination of  the  urine  in  this  case  disclosed  a  colon  bacillus  infection  Avith 
some  pus,  and  this  persisted  until  after  the  operation.  When  the  patient  finally 
left  the  hospital  there  was  no  infection  and  no  pus  in  the  urine. 

A  case  of  this  kind,  in  a  young  unmarried  woman,  coming  on  insidiously, 
and  with  an  almost  clear  urine,  is  highly  suggestive  of  tuberculosis ;  in  this 
case  it  was  only  after  the  administration  of  tuberculin  and  the  repeated  inocu- 
lation of  guinea-pigs  with  negative  results  that  it  was  excluded. 

SYMPTOMS. 

Local  Symptoms. — Frequency  of  micturition  is  one  of  the  cardinal 
symptoms  of  cystitis,  and  there  is  no  true  cystitis  without  it,  yet  on  the  other 
hand  there  may  be  urgent  desire  and  great  frequency  without  any  cystitis  at  all. 
This  is  the  rock  on  which  the  general  practitioner  is  often  wrecked,  when  he 
hazards  making  a  diagnosis  of  cystitis  from  frequency  of  urination  alone. 
The  frequency  varies  from  an  evacuation  every  hour  or  half  hour  to  one  every 
ten  or  fifteen  minutes  day  and  night,  or  to  a  constant  tenesmus  and  strangury. 


548  CYSTITIS. 

The  desire  to  void  oftener  than  usual  is,  as  a  rule,  the  first  symptom  noted 
bj  the  patient  and  the  last  to  subside,  often  persisting  even  after  the  entire 
disappearance  of  pus  and  bacteria  from  the  urine.  Frequent  urination,  there- 
fore, and  pain,  are  the  chief  symptoms  by  -^hicli  the  patient  judges  as  to  her 
OA^TL  improvement. 

Pain  is  a  symptom  not  always  felt  at  first;  it  usually  follows  frequency  of 
urination.  "When  felt  it  is  localized  in  the  bladder  and  does  not  radiate ;  it  is 
of  a  burning,  cutting,  bearing-down  character,  and  varies  from  a  simple  annoy- 
ance at  the  time  of  urination  or  before  it  to  an  aggravated  continual  suffering, 
from  which  there  is  no  relief,  day  or  night.  The  pain  of  a  cystitis  is  easily 
provoked  by  the  introduction  of  a  soim-d  into  the  bladder,  a  proceeding  which 
is  often  followed  by  bleeding. 

In  all  cases  of  cystitis,  the  pelvis  ought  to  be  examined  as  a  matter  of 
routine,  to  see  if  there  is  any  tumor  pressing  on  the  bladder  or  any  inflam- 
matory  disease   about   the   uterus. 

The  presence  of  pus  in  the  urine  may  simply  be  due  to  a  lingering 
gonorrheal  urethritis,  which  is  usually  manifested  by  a  reddened  sensitive  ex- 
ternal urethral  orifice.  A  pyelitis  is  distinguished  by  the  presence  of  pus  in 
tlie  urine,  without  the  presence  of  the  other  sigTis  of  a  cystitis,  and  also  by  the 
amount  of  albumen  found  in  the  urine,  which  is  larger  than  can  be  accounted 
for  by  the  amount  of  pus  found.  A  urologist,  by  catheterizing  the  ureter,  will 
be  able  to  trace  the  pus  to  its  source  above.  As  I  have  said  elsewhere,  an 
acid  pyuria,  without  organisms  easily  found  and  growing  on  the  common 
culture  media  such  as  agar  or  gelatin,  is  due,  as  a  rule,  to  a  tubercular  kidney. 

General  Symptoms. — Fever,  headache,  loss  of  appetite,  constipa- 
tion, and  emaciation,  are  noted  only  in  the  most  aggTavated  cases  of 
cystitis.  By  the  time  the  patient  is  so  far  reduced,  she  keeps  her  bed,  as  a  rule, 
all  the  time.  In  the  presence  of  such  general  symptoms,  especially  if  they 
persist,  the  practitioner  should  quickly  make  up  his  mind  that  he  is  dealing 
with  some  severer  ti'ouble  of  which  the  cystitis  is  only  a  part.  In  the  vast 
majority  of  such  cases  the  trouble  is  a  kidney  infection. 

DIAGNOSIS. 

There  can  be  little  doubt  that  a  cystitis  exists  when  the  patient  is  troubled 
with  frequent  urination  and  passes  milky  or  turbid  urine  with  pain.  It  is 
important  to  examine  the  urine  immediately  when  passed,  so  as  not  to  mistake 
urine  rendered  cloudy  by  chilling  and  deposition  of  phosphates  for  infected 
urine  carrying  pus.  Only  the  more  marked  cases  of  cystitis  can  be  diagTiosed 
in  this  rough  manner.  The  better  plan  is  to  cleanse  the  orifice  of  the  urethra 
thoroughly,  take  a  catheterized  specimen,  and  either  examine  it  microscop- 
ically, or  send  it  to  a  pathologist  for  examination  and  report.  Five  grains 
of  chloral  or  ten  drops  of  chloroform  to  the  ounce  will  keep  the  urine  from 
undergoing  decomposition  on  the  way. 


DIAGNOSIS.  549 

I  might  lay  down  the  general  rule  that  whenever  a  patient  com- 
plains of  frequency  of  urination  and  the  trouble  is  persistent, 
the  physician  should  make  a  microscopic  examination  of  the 
urine.  If  the  urine  has  been  voided,  two  serious  sources  of  contamination 
must  always  be  allowed  for:  first,  a  little  admixture  of  leucorrheal  dis- 
charge furnishes  pus,  and  in  the  second  place  smegma  bacilli  often 
give  rise  to  a  faulty  diagnosis  of  tuberculosis.  It  is  necessary,  therefore,  in 
case  pus  or  suspected  tubercle  bacilli  are  found,  to  secure  a  catheterized 
specimen  for  the  next  examination.  This  will  often  relieve  a  seemingly  serious 
situation. 

The  practitioner,  if  inclined  to  do  a  little  experimental  work  with  a  guinea- 
pig,  can  easily  clear  up  the  diagnosis  of  a  tubercular  cystitis  by  collecting  a 
little  of  the  sediment  of  the  urine  in  a  hypodermic  syringe  and  injecting  it 
under  the  skin  of  the  groin  of  a  guinea-pig,  after  carefully  washing  and  shav- 
ing the  area  to  be  punctured.  If  tubercle  bacilli  are  present,  distinct 
nodules  can  be  felt  two  or  three  weeks  afterward  in  the  enlarging  inguinal 
glands,  and  if  the  animal  is  killed  a  little  later,  the  tubercular  glands  are  easily 
recognized.  A  small  dose  of  tuberculin,  say  one  to  three  miligrams,  given 
under  the  skin,  will  also  provoke  a  decided  fever  when  the  disease  is  tubercu- 
lar, the  temperature  rising  to  103°,  104°,  105°  F.,  with  marked  local  reaction 
at  the  site  of  the  disease.  The  local  reaction  manifests  itself  in  pain  and  also 
by  the  excretion  of  bacteria  and  pus  in  the  urine. 

If  pus  is  found  in  the  voided  urine,  it  must  be  remembered  that  it  may 
come  from  the  kidney,  even  when  the  patient  has  definite  vesical  symptoms. 
The  general  rule  may  be  laid  down  that  in  every  case  of  cystitis,  the  kidneys 
must  be  borne  in  mind  by  the  investigator  from  the  very  begin- 
ning of  his  treatment  to  the  end,  unless  he  is  able  himself,  or  has 
called  in  a  friend  skilled  in  urology,  to  catheterize  the  ureters,  and  to  prove 
that  while,  urine  containing  pus  comes  from  the  bladder,  that  wdiich  comes 
from  the  kidneys  is  free  from  it. 

Whenever  there  is  any  fever  associated  with  a  cystitis,  for  which  there  is 
no  other  obvious  cause,  and  such  conditions  as  malaria  are  excluded  by  blood 
examinations,  the.  examiner  must  always  suspect  a  latent  pyelitis  as  the 
primary  source  of  the  cystitis  or  of  the  cystic  symptoms.  A  pyelitis  of  this 
kind  often  gives  rise  to  no  symptoms  whatever  tending  to  draw  attention  to 
its  existence. 

A  valuable  fact  to  bear  in  mind  here,  is  that  in  pyelitis  the  percentage 
proportion  of  albumen  is  generally  markedly  greater  than  that  found  in  a 
cystitis  containing  a  like  amount  of  pus.  Moreover,  the  cystitis  albumen  ring 
is  thin  and  faint,  while  pyelitis  in  the  greater  number  of  cases  yields  a  well- 
defined  ring. 

When  there  is  a  proteus  infection  and  in  consequence  an.  alkaline 
urine,  the  pus  cells  become  converted  into  a  mucoid  substance,  the  urine  is 
slimy  and  stringy,  and  contains  no  well-defined  pus  cells  which  can  be  seen 


550 


CYSTITIS. 


under  tlie  microscope.     This  form  of  cystitis  may  be  paradoxically  called  a 
pyuria  without  pus. 

As  already  said,  a  patient  who  has  a  ^jersistent  acid  pyuria,  lasting  for 
months  and  years  and  slowly  getting  worse,  has,  as  a  rule,  a  tubercular  kidney. 
The  great  majority  of  tubercular  kidneys  give  such  a  history  as  this  and  they 
generally  suffer  for  years  before  the  disease  is  recognized.  When  a  patient 
has  a  pyuria  with  some  symptoms  of  cystitis  and  no  bacteria  are  found  in  the 
urine,  after  making  the  usual  examination,  it  must  always  be  remembered  that 
the  later  histories  of  similar  cases  have  often  proved  them  to  be  tubercular. 
The  colon  bacillus  is  the  commonest  infecting  organism,  and  it  may  fol- 
low the  introduction  of  an  unclean  catheter,  or  even  repeated  catheterizations 
carefully  performed,  in  the  puerperal  period  or  after  gynecological  operations 
when  resistance  is  lowered.  An  intense  distressing  cystitis,  with  pus  and  blood 
in  an  alkaline  urine,  due  to  a    p  rote  us    infection,    is  often  encountered. 

The  physician  ought  not  to  continue 
to  treat  a  case  indefinitely,  unless 
he  notes  marked  improvement  as 
the  result  of  his  efforts ;  if  he  does 
not,  it  is  imperative  to  directly  in- 
spect the  bladder  through  an  open- 
air  cystoscope  (see  Fig.  150).  There 
are  urologists  in  every  large  city 
who  are  familiar  with  these  instru- 
ments and  capable  of  using  them 
skilfully.  Many  general  practition- 
ers, especially  those  accustomed  to 
use  throat  instruments,  find  them- 
selves perfectly  competent  to  employ 
these  little  instruments,  to  examine 
the  bladder,  to  make  a  diagnosis, 
and  to  apply  treatments.  It  is  true 
that  the  cystoscope  has  thus  far 
rested  for  the  most  part  in  the 
hands  of  specialists,  but  that  is 
simply  because  it  is  comparatively 
new  and  its  field  is  a  new  one; 
moreover,  the  technic  of  the  treat- 
ment of  these  disorders  has  been 
in  the  process  of  evolution.  Xow 
that  all  difficulties  and  obstacles  are  overcome,  there  is  no  reason  why  the 
general  practitioner  should  not  take  over  as  much  of  this  work  as  he  has  incli- 
nation and  skill  to  assume. 

The  examination  is  made  with  the  following  instruments  and  acces- 
sories : 


Fig.  150. — Shotvs  Ma^-xer  of  Holding  Cysto- 
scope, Preparatory  to  its  Introductiox  into 
THE  Bladder.  The  thumb  presses  upon  the 
handle  of  the  obturator. 


Fig.  151. — Shows  Patient  in  the  Knee-breast  Posture.  The  left  hand  of  the  examiner  separates 
the  labia  and  exposes  the  urethra,  while  the  right  hand  begins  the  introduction  of  the  cystoscope. 
Note  the  upward  direction  which  the  cystoscope  first  takes. 


H^-C^^'^^     ^^^^^^ 


Fig.  152.--Shows  Cystoscope  in  Place.     Note  the  change  in  direction  which  has  taken  place  in  the 
axis  of  the  cystoscope,  which  is  now  pointed  to  the  posterior  wall  of  the  symphysis  pubis. 

551 


552 


CYSTITIS. 


A  little  pledget  of  cotton  tied  to  a  thread  to  convey  cocain  into 
the  urethra. 

A   calibrator    or  dilator  to  dilate  the  external  urethral  orifice. 

A  speculum   with  which  to  look  into  the  bladder. 

A   head   mirror    to  reflect  an  electric  light  or  daylight  into  the  bladder. 

A  simple  suction  apparatus  to  empty  the  bladder  of  any  remain- 
ing urine. 

An    applicator    for  treatments. 

An  examination  of  this  kind  can  be  made,  as  a  rule,  under  local  anesthesia 
by  inserting  a  pledget,  saturated  with  a  ten  per  cent  solution  of  cocain,  just 
inside  the  urethral  orifice.  In  ten  minutes  the  mucosa  will  be  so  benumbed 
that  the  little  conical  dilator  can  be  inserted,  and,  with  a  rapid  movement,  the 
urethra  can  be  stretched  wide  enough  to  admit  a  'No.  10  speculum  (ten  milli- 
metres in  diameter).  The  speculum  is  then  introduced,  as  shown  in  the  fig- 
ures (see  Figs.  151  and  152),  the  patient  being  in  the  knee-breast  posture.  It 
must  be  remembered  that  the  urethra  describes  an  arc  around  the  symphysis, 


Fig.  153. — Shows  OsTtrRATOR  Remo\'ed  ant>  the  Method  of  Usixg  Light  and  Head  Mieror  in  the 
Inspection  of  the  Interior  of  the  Bladder. 


and  in  introducing  the  speculum,  it  must  be  made  to  follow  a  similar  arc. 
The  light  is  then  reflected  into  the  bladder  from  the  head  mirror,  and  the  entire 
inner  surface  can  be  easily  inspected  (see  Eig.  153).  If  there  is  an  accumu- 
lation of  urine  in  the  vertex,  it  can  be  removed  with  the  suction  apparatus 


DIAGNOSIS. 


553 


(see  Fig.  154).  If  this  apparatus  is  sterile,  uncontaminated  urine  can  thus 
be  secured  and  examined  bacteriologically  as  well  as  chemically.  If  the  blad- 
der is  in  a  very  bad  condition,  it  is  preferable  to  make  the  first  examination 
under  complete  anesthesia,  so  as  to  avoid  suffering  and  any  straining  efforts. 
In  looking  into  a  normal  bladder,  the  walls  appear  dull  and  whitish,  and  are 

traversed  by  vessels  like  the  background  of  the  eye, 
which  divide  up  like  the  little  branches  of  a  stream, 
leaving  between  them  the  whitish  non-vascular  areas. 
When  there  is  any  inflammation,  the  white  areas  be- 
come flushed,  pale  red,  or  rose  red,  or  even  intensely 


Fig.  154. — Ili^ustrates  the  Use  of  Suction  Apparatus  for  Removing  Urine  which  Accumulates 

IN  the  Bladder  during  Examination. 

beefy  red.  The  mucosa  swells  and  becomes  hazy,  and  the  vessels  disappear, 
until,  in  the  most  severe  "cases,  no  vessels  at  all  are  visible.  In  milder  cases 
of  inflammation,  the  cystitis  is  seen  to  be  localized  about  the  trigonum,  or  upon 
the  posterior  wall,  or  at  the  vertex.  There  is  often  an  intense  area  of  inflam- 
mation, which  gradually  shades  off  into  neighboring  sound  tissues. 

Our  present  conception  of  cystitis  influenced  as  it  has  been  by  these  local 
examinations  is  very  different  from  that  entertained  two  decades  ago.  The 
idea  of  cystitis  then  was  that  the  whole  inner  surface  of  the  bladder  was 
inflamed.  ^N'ow  it  is  known  that  the  patchy  cystitis,  with  areas  of  normal 
bladder  mucosa  between  the  inflamed  foci,  is  much  the  commonest  form. 

I  cannot  lay  too  great  emphasis  upon  the  importance  of  not 
making   a   diagnosis   of  cystitis   from   the    symptoms   of   frequent 


554  CYSTITIS. 

and  painful  micturition  alone.  These  two  symptoms  may  be  found 
Avith  stone  in  the  kidney,  stone  or  foreign  body  in  tlie  bladder,  or  the  irrita- 
tion produced  by  a  neighboring  gynecological  inflammation.  To  make  a 
probable  diagnosis  of  cystitis  there  must  be  the  added  element 
of  pus  in  the  urine;  though  even  here  the  disease  may  not  reside  in 
the  bladder  but  in  the  renal  pelvis  above,  in  some  exceptional  cases.  The 
crucial  sign  of  cystitis  is  the  inflamed  bladder  as  seen  through 
the   cystoscope. 

Tubercular  forms  of  cystitis  are  apt  to  show  areas  of  ulceration, 
and  if,  as  is  usually  the  case,  the  disease  is  a  descending  one,  the  most  marked 
ulceration  is  around  the  ureteral  orifice  of  the  affected  side.  Distinct  tubercles 
are  not  often  seen.  In  proteus  cystitis,  the  bladder  shows  patches  of 
intense,  almost  glistening  white  concretions,  seated  on  a  base  of  intense  inflam- 
mation. The  value  of  such  a  local  examination  is  evidently  very  great.  ISTot 
only  is  it  a  source  of  encouragement  to  see  that  the  disease  is  often  more 
localized  than  had  been  suspected,  but  it  is  valuable  for  the  sake  of  comparison 
from  week  to  week  in  determining  whether  or  not  the  patient  is  improving, 
or  whether  there  is  some  rebellious  area  which  refuses  to  advance  further  on 
the  road  toward  healing. 

Differential  Diagnosis. — Cystitis  may  be  confused  with  simple  frequent 
urination    (pollakiuria). 

Trigonal  hyperemia. 

Pelvic  tumors  and  inflammatory  conditions. 

Urethritis. 

Ureteritis. 

Pyelitis  of  various  kinds. 

Tuberculosis  of  the  kidney. 

Stone  in  the  bladder  and  kidney. 

If  pus  and  bacteria  are  absent  the  disease  cannot  be  a  cystitis,  even  though 
the  patient  urinates  frequently.  Frequent  urination  of  this  kind  is  foimd  in 
diabetes,  as  well  as  in  hyperemia  of  the  trigonum  of  the  bladder  in  nervous 
patients,  where  the  urine  is  excessively  acid. 

TREATMENT. 

Preventive  Treatment. — Here  as  elsewhere  in  medicine,  it  is  far  more 
important  to  prevent  the  disease  and  all  its  attendant  suffering,  than  to  cure 
it  when  already  arisen;  for  it  is  always  easier  to  prevent  a  disease  than  to 
cure  it.  Many  cases  of  cystitis  could,  undoubtedly,  be  avoided  by  careful 
prophylaxis.  These  are,  especially,  those  which  follow  confinements  and  sur- 
gical operations,  when  it  is  very  important  to  watch  the  bladder  and  to  make 
sure  that  it  does  not  become  overdistended,  atonic,  and  liable  to  accumulate 
large  amounts  of  residual  urine  which  is  prone,  in  the  weakened  condition  of 
the  patient,  to  become  foul. 


PEEVENTIVE    TREATMENT.  555 

following  confinements  it  is  important  to  steer  between  difficult  extremes : 
on  one  hand  catheterizing  too  often,  and  on  the  other  hand,  not  often  enough 
when  there  is  a  tendency  to  overdistention  of  the  bladder.  It  is  a  good  plan 
in  a  first  confinement  to  teach  the  patient  before  delivery  how  to  use  a  bed- 
pan in  emptying  the  bladder  as  she  lies  on  her  back  in  bed.  If  the  bladder 
can  be  felt  after  confinement  distended  above  the  symphysis,  it  ought  to  be 
emptied.  One  important  way  of  avoiding  overdistention  of  the  bladder  is 
always  to  use  the  catheter  to  empty  it  before  applying  the  obstetric  forceps. 
The  discharges  are  kept  sweeter  and  cleaner,  if  every  time  the  patient  is 
changed  or  catheterized,  a  powder  (one  part  iodoform  and  seven  parts  boric 
acid)  is  sprinkled  within  the  outlet. 

ISTot  uncommonly,  a  patient  who  is  voiding  very  frequently  is  really  suf- 
fering from  overdistention  of  her  bladder.  If  there  is  much  lower  abdominal 
pain,  and  a  careful  palpation  of  the  lower  abdomen  or  vaginal  examination 
justifies  the  suspicion  that  the  bladder  is  overdistended,  the  question  is  quickly 
set  at  rest  by  catheterization. 

On  the  other  hand,  it  is  necessary  to  be  careful  not  to  interfere  too  early 
or  too  often.  There  is,  on  the  part  of  some  surgeons,  a  tendency  to  meddle 
too  much  with  the  bladder  and  to  catheterize  with  too  great  a  regularity. 
There  should  be  no  prescribed  rule  establishing  the  use  of  the  catheter  in  all 
cases  at  certain  intervals  of  time.  Many  patients,  if  they  are  allowed  to  suffer 
a  little  inconvenience  from  the  distending  bladder,  will,  from  this  very  fact, 
urinate  spontaneously  after  waiting  a  while,  and  will  then  be  able  to  take  care 
of  the  vesical  function  themselves.  Moreover,  if  the  catheter  is  resorted  to 
early,  the  patient  becomes  dependent  upon  it,  and  its  use  may  have  to  be  con- 
tinued for  several  weeks.  With  the  protracted  use  of  the  catheter,  the  risk 
of  infecting  the  bladder  is  enormously  enhanced,  and,  like  the  pitcher  which 
goes  often  to  the  well,  the  break  in  the  technic  with  resulting  infection  occurs 
at  last,  and  cystitis  is  established. 

As  regards  the  avoidance  of  post-operative  cystitis,  too  much  im- 
portance cannot  be  laid  upon  not  using  the  catheter  at  all.  A  patient,  even 
after  a  severe  operation,  had  better  be  propped  up  in  bed  supported  by  her 
nurse  than  undergo  a  catheterization.  It  is  also  advantageous  to  teach  the 
patient  to  void  urine  when  lying  down  before  the  operation.  In  the  last  two 
thousand  cases  in  my  service  at  the  Johns  Hopkins  Hospital  the  patients  were 
not  catheterized  and  there  were  only  twenty-four  cases  of  marked  cystitis  after 
operation.  This  is  in  decided  contrast  to  our  old  records,  where  every  patient 
was  catheterized  as  a  matter  of  routine  for  a  number  of  days.  Twenty-two 
of  these  twenty-four  cases  followed  abdominal  operations ;  but  in  all  of  them 
cystitis  developed  afterwards,  in  spite  of  the  fact  that  there  was  no  catheteriza- 
tion. The  average  case  of  post-operative  cystitis,  due  to  catheterization  of  the 
urethra  when  there  has  been  no  serious  disturbance  of  the  bladder  by  opera- 
tion, is  a  mild  affair  and  yields  readily  to  treatment.  On  the  other  hand,  in 
the  extensive  operations  necessitated  by  cancer  of  the  cervix,  there  is  such 


556  CYSTITIS. 

destruction,  of  both  the  vascularization  and  the  innervation  of  the  bladder, 
that  a  cystitis  may  develop  which  is  extremely  obstinate  and  in  some  cases 
incurable. 

In  using  the  catheter  all  necessary  precautions  should  be  taken  in  every 
instance.  In  the  first  place,  the  nurse  or  the  doctor  who  handles  infected  cases 
ought  to  wash  the  hands  thoroughly,  scrubbing  them  with  soap  and  hot  water 
after  every  treatment,  as  well  as  before  each  new  treatment.  The  patient  to 
be  catheterized  is  then: 

(1)  Exposed  as  she  lies  upon  her  back,  with  knees  drawn  up  and  separated. 
The  vulva  is  held  widely  open  with  thumb  and  forefinger  of  the  left  hand,  so 
as  to  give  a  perfect  exposure  of  the  urethral  orifice. 

(2)  It  is  a  good  plan  to  draw  a  little  rubber  finger  cot  on  thumb  and  fore- 
finger of  right  hand. 

(3)  A  sterile  dish  containing  a  warm  boric  acid  solution  and  some  pledgets 
of  cotton  about  three  centimetres  in  diameter,  should  be  placed  on  the  bed  not 
far  away  from  the  genitalia. 

(4)  A  gauze  or  cotton  pad  is  placed  under  the  patient,  or  perhaps  a 
curved  basin. 

(5)  The  nurse  then  takes  up  the  cotton  in  the  boric  acid  solution  with  a 
pair  of  sterile  forceps. 

(6)  She  cleanses  thoroughly  the  urethral  orifice  and  the  adjacent  portions 
of  the  vestibule,  using  several  pledgets  of  cotton  one  after  the  other,  and  apply- 
ing the  solution  efi^ectively,  but  taking  care  not  to  rub  hard,  and  not  to  hurt 
the  patient  or  abrade  the  delicate  tissues.  Having  thus  cleansed  the  field  she 
then  takes  a  sterile  glass  catheter  from  a  receptacle.  The  catheter  with  a  piece 
of  rubber  tubing  on  the  end,  three  or  four  inches  long,  is  held  delicately  poised 
between  thumb  and  index  finger. 

(Y)  The  end  of  the  catheter  is  dipped  in  sterile  sweet  oil,  introduced  into 
the  urethral  orifice,  and  with  a  slightly  curved  motion,  following  the  curve  of 
the  under  surface  of  the  symphysis  by  dropping  the  outer  end  as  it  is  carried 
upwards  and  inwards,  it  is  introduced  into  the  bladder.  The  catheter  must 
never  be  grasped  firmly  with  the  fist,  as  though  the  nurse  were  determined 
to  overcome  any  obstacles  encountered  by  a  main  force ;  neither  must  it  be 
pushed  straight  in,  as  though  the  urethra  were  a  straight  tube. 

(8)  The  urine  running  out  of  the  rubber  tube  is  collected  for  examina- 
tion, if  desired,  in  a  suitable  vessel.  Uncontaminated  urine  is  easily  secured 
for  bacteriological  examination  by  drawing  the  rubber  tube  off  from  the  end 
of  the  catheter  while  the  urine  is  still  running,  and  letting  a  few  drops  or  a 
few  cubic  centimetres  run  into  a  sterile  agar  tube. 

Unless  the  nurse  is  skilled  in  catheterizing  she  would  do  better,  I  think, 
to  use  a  soft-rubber  catheter,  which  finds  its  own  way  up  the  urethra. 

The  two  objects  in  catheterization  are,  first,  to  introduce  the  cath- 
eter without  carrying  in  any  infectious  material,  which  is  effected 
by    exposure    and    cleanliness;    and,    second,    to    avoid    any    trauma    or 


MEDICINAL    TREATMENT.  557 

laceration  of  the  urethral  mucosa.  If  the  second  rule  is  observed 
the  catheterization  is  done  without  hurting  the  patient  at  all. 

I  am  aware  that  the  above  method  of  catheterization  sounds  very  much 
like  a  small  surgical  operation,  but  unless  all  these  precautions  are  taken,  it 
is  impossible  to  avoid  causing  a  certain  number  of  distressing  cases  of  cystitis, 
and  it  is  a  matter  of  primary  importance  that  our  nurses,  as  well  as  our  prac- 
titioners, should  be  taught  to  consider  this  little  procedure  as  parallel  in  dignity 
to  a  minor  surgical  procedure.  It  is  the  constant  necessity  of  exercising  such 
care  as  this  in  every  relationship  between  themselves  and  the  patient  which 
raises  the  calling  of  physician  and  nurse  to  the  dignity  of  a  skilled  profession, 
and  makes  the  difference  between  a  true  practitioner  and  a  quack.  When  the 
physician  finds  that  it  is  going  to  be  necessary  to  catheterize  his  patient  more  or 
less  frequently  during  a  convalescence,  as  after  a  severe  confinement,  one  of  the 
best  prophylactic  agencies  is  the  use  of  uro tropin,  say  ten  gTains  three  times 
a  day  until  the  danger  of  infection  is  over.  Urotropin  finds  its  best  field  as  a 
preventive  in  such  cases,  and  as  an  indispensable  adjuvant  in  treating  fresh 
infections ;  it  is  less  effective  in  old,  well-established  cases  of  cystitis.  It  seems 
to  have  more  effect  upon  the  colon  bacillus  than  upon  any  other  organism; 
it  is  useless  in  cases  of  tuberculosis,  and  is  probably  most  effective  in  cases  of 
cystitis  and  pyelitis  following  typhoid  fever.  In  surgical  cases,  prophylaxis 
can  do  a  great  deal  to  prevent  cystitis  following  and  complicating  the  convales- 
cence. With  this  in  view,  the  surgeon  should  handle  the  bladder  as  little  as 
possible  and  avoid  all  bruising  of  its  tissues,  especially  any  violence  in  rubbing 
down  or  detaching  the  bladder  from  the  cervix  uteri.  If  the  bladder  is  widely 
detached  from  the  uterus,  as  in  hysterectomy,  the  vaginal  and  peritoneal 
surfaces  should  be  brought  together  so  as  to  cover  over  the  wounded  sur- 
faces and  limit  the  area  of  suppuration,  protecting  the  bladder.  In  our 
hysterectomies  for  cancer  of  the  cervix,  my  former  resident,  Dr.  John  A. 
Sampson,  found  that  a  drainage  of  the  bladder  by  artificial  vesico-vaginal 
fistula  prevented  the  occurrence  of  cystitis,  which  was  exceedingly  common 
without  it. 

Treatment  of  an  Existing  Cystitis. — In  treating  a  cystitis  which  has  already 
become  established,  we  must  at  once  separate  those  cases  which  come  on  in  the 
young  gradually  and  without  apparent  cause,  or  with  such  an  alleged  cause  as 
catching  cold,  as  well  as  cases  of  long  standing,  from  those  which  have  begun 
within  a  period  of,  say,  a  few  weeks,  from  some  easily  assignable  cause,  such  as 
a  trauma  from  operation  or  a  confinement.  Cystitis  in  the  young  is 
very  apt  to  be  due  to  a  tubercular  infection,  and  this  fact  must  always 
be  borne  in  mind  until  the  nature  of  the  infecting  organism  is  definitely  and 
positively  known.  All  persistent  acid  pyurias  in  young  people  are 
presumptively  tubercular  until  the  contrary  is  proved.  If 
tubercle  bacilli  are  found  in  the  urine,  the  case  is  not  one  which  is  amen- 
able to  medical  treatment.  When  tubercle  bacilli  are  found,  the  case 
is  almost  certainly  one   of  tuberculosis   of  the  kidney,  with   sec- 


558 


CYSTITIS. 


ondary  involvement  of  the  bladder.  It  is  often  hard  to  convince  a 
general  practitioner  of  this  fact,  because  these  patients  not  only  frequently 
eonijilain  first  of  the  bladder,  but  ofttimes  the  entire  complaint  throughout  the 
whole  illness  is  vesical,  so  that  great  astonishment  is  expressed  when  the  con- 
jecture is  hazarded  by  the  specialist  that  the  kidney  is  the  real  seat  of  the 
disease. 

A    gonorrheal    cystitis    usually  dates  from  a  florid  attack  of  gonor- 
rhea, affecting  the  genitalia  as  well  as  the  urinary  organs,  and  beginning  with- 
an  acute  urethritis  and  cystitis. 

It  is  important  to  remember  that  an  infection,  primarily  tubercu- 
lar, is  often  followed  by  the  invasion  of  other  pus-producing 
organisms,  which  cause  more  or  less  extensive  suppuration  and  a  marked 
febrile  reaction.  Albarran,  of  Paris,  has  dra^vn  particular  attention  to  this 
class  of  cases. 

A  cystitis  beginning  to  run  an  acute  course,  with  frequent  urination  and 
the  passage  of  pus,  mucus,  and  blood,  ought  not  to  be  subjected  to  any  active 
local  treatments.  Catheterizations  and  irrigations,  and  local  medications  of 
all  sorts,  as  a  rule,  only  serve  to  aggTavate  the  disease,  which  often  tends  to 
heal  spontaneously  without  meddlesome  interferences.  The  best  treatment  for 
an  acute  cystitis  is  absolute  rest  in  bed,  a  nutritious  soft  or  liquid  diet,  and 
abundant  diluents  by  the  mouth,  say  a  tumbler  of  water  containing  twenty 
grains  of  citrate  of  potash  every  two  hours.  If  the  pain  is  severe,  a  bella- 
donna and  opium  suppository  is  the  best  sedative  we  can  use. 

19   Extract  of  opium gr.  i 

Extract  of  belladonna gr.  i 

01.   theobromse    q.   s. 

M.     et  ft.  suppository  1.     Mitte  tales  vj. 

S.       One  suppository  every  6  to  8  hours  if  pain  is  severe. 

A  good  suppository  is: 


^   Trional gr- 

Codeige    • g^- 

M.     et  ft.  suppository  1. 


I  would,  as  a  rule,  confine  the  patient  to  a  milk  diet  or  its  equivalent,  and 
allow  fruits,  but  cut  off  all  red  meats  and  condiments.  A  prolonged  hot 
vaginal  douche  (110°  E.)  g-iven  for  ten  to  fifteen  minutes  twice  a  day 
may  alleviate  the  inflammation.  Hot  applications,  poultices,  or  fomentations 
of  flannel  wrung  out  of  hot  water  over  the  lower  abdomen  are  valuable 
adjuvants. 

Urotropin  should  be  given,  five  grains  every  three  or  four  hours  for 
some  days  at  the  beginning.  If  this  makes  the  urine  more  irritating,  the  dose 
should  be  lessened  or  suspended. 


LOCAL    TREATMENT. 


559 


A  good  mixture  in  the  acid  cases  is: 

I^   Pot.  citrat. 3j v 

Tr.  hyoscyanii   fSvj 

Elix.  simpl q.  s.  ad.  f 5vj 

S.     Tablespoonful  every  2-3  hours  in  water. 

I  find  the  following  drugs  of  occasional  assistance:  Fluid  extract  of 
triticum  rejens,  fluid  extract  of  zea  mais,  oil  of  sandal  wood, 
copaiba,    methylene   blue,    sweet    spirits    of   nitre. 

I  do  not  know  anything  as  to  the  real  value  of  the  old  remedies  once  held 
in  such  repute,  namely,  uva  ursi,  buchu,  pareira  brava,  pipsissewa. 
The  methylene  blue  in  doses  of  three  grains  three  times  a  day,  in  capsules, 
sometimes  quiets  pain,  but  does  not  control  the  disease. 

Triticum  and  zea  mais  serve  to  make  the  urine  bland,  given  in  doses 
of  half  a  teaspoonful,  well  diluted,  every  three  or  four  hours.  Oil  of  san- 
dal wood  and  copaiba  are  given  in  five  to  ten  minim  capsules  after  food. 
They  sometimes  do  good,  but  oftener  they  upset  the  stomach.  Sweet  spirits 
of  nitre  in  doses  of  one  teaspoonful  every  two  or  three  hours,  well  diluted, 
also  relieves  pain  and  is  valuable  in  mild  cases.  Tincture  of  hyoscyamus 
in  thirty  drop  doses  may  be  given  every  two  or  three  hours  by  mouth.  It  is 
well  to  dilute  freely  all  medi- 
cines taken  by  mouth. 

If  instead  of  subsiding,  the 
case  continues  to  run  a  peracute 
course,  as  in  diphtheritic  cystitis 
or  in  the  sloughing  form  follow- 
ing a  severe  labor,  but  one  plan 

of  treatment  is  left,  and  that  is  J^  /f 

to  open  and  drain  the  bladder 
through  the  vagina.  These  drain- 
age cases  are  very  much  helped 
by  placing  the  patient  in  a  hot 
water  bath  for  several  hours 
every  day  (Hunner). 

Local   Therapy. -In.  cystitis     ''^'^^IS.^S'^T^.T'SLrj^l 

which    is    not    running    an    acute  mtrodxiced  and  the  clamp  re- 

"  moved  from  the  tubing,  allow- 

COUrse,     local    therapy    can    do  ing  the  urine  to  escape.     The 

-  _  -  ,         ,    .  clamp  is  then  re-applied,  after 

a    great     deal.        I     would     advise  which  the  contents  of  the  bulb 

.1  I,  -n        .  ^  /^^^^1  is  emptied  into  the  bladder. 

the    lollowmg    plan:     (1)     Ine 

symptoms    should    be    carefully 

and  minutely  written  out:  frequency  of  urination,  etc.,  amount  and  character 

of  pain,  the  appearance  of  the  urine,  and  the  amount  of  sediment  of  pus  after 

standing  for  a  definite  length  of  time. 

(2)   A  short  course  of  treatment,  lasting  a  few  weeks,  should  then  be  insti- 


560 


CYSTITIS. 


tilted.  The  jJaii  iiiu>t  lir  definite,  and  the  physician  slioiild  make  up  his  mind 
not  to  contiune  it  indefinitely,  but  to  abandon  it  for  a  more  aggressive  course 
in  case  there  is  no  marked  improvement  in  a  reasonable  period  of  time.  A 
mild  course  of  treatment  consists  in  rest,  keeping  the  patient  at  the  same  time 
as  much  in  the  fresh  air  as  possible,  and  in  the  winter  out  in  the  sunshine, 
the  due  regTilation  of  the  bowels,  and  daily  or  every  other  day  treatments  of 
the  bladder.  The  simplest  plan  of  treatment  is  the  following:  A  Dickinson 
two-way  glass  catheter  (see  Fig.  155)  is  used,  with  a  bulb  holding  about  an 
ounce  of  a  1:1500  nitrate  of  silver  solution  on  the  upper  catheter. 
The  catheter  is  introduced  with  extreme  gentleness,  and  the  urine  in  the  blad 


Fig.  156. — iShotvixg  Jlovi-  a  Dickixsox  or  axt  Ttvo-wat  Catheter  Cax  be  Used  ix^  Irrigatiox  of 

THE  Bladder. 


der  allowed  to  run  out.  Then  after  stopping  up  the  lower  end  of  the  catheter, 
the  bulb  is  slowly  squeezed  until  the  silver  solution  is  forced  into  the  bladder. 
The  patient  retains  this  fifteen  or  twenty  minutes,  if  possible,  before  voiding 
again.  If  the  1 :  1500  solution  gives  no  discomfort,  the  sti'ength  should  gTad- 
ually  be  increased  until  1 :  1000,  1 :  500,  or  even  1 :  100  is  used. 


LOCAL    TREATMENT.  56J 

Formula  for  solution  of  nitrate  of  silver  1 :  1500 : 

^   Arg.  nitrat gr.  ^ 

Acidi  borac gr.  vj 

Aq.  destil fgj 

M.     S.  Inject  warm  into  bladder. 

A  strong  stock  solution  of  boric  acid  may  be  made  up  and  diluted  as  used. 
If  these  instillations  do  not  give  prompt  relief,  or  for  any  reason  are  not  well 
borne,  irrigations  may  be  used,  the  bladder  being  washed  out  with  a  half 
saturated  warm  solution  of  borax,  or  with  a  boracic  acid  solu- 
tion as  hot  as  can  be  borne,  following  this  by  an  injectioii,  through  the 
irrigating  funnel  (see  Fig.  156),  of  a  nitrate  of  silver  solution  1:1000 
or  stronger  as  the  patient  is  able  to  bear  it.  In  some  cases  the  irrigations 
and  instillations  may  be  alternated  with  advantage.  After  a  certain 
line  of  treatment  has  been  carried  out  for  two  or  three  weeks,  there  is  often 
a  distinct  gain  in  changing  to  another  line  of  treatment  for  a  time.  It  seems 
as  though  we  catch  the  bladder  by  surprise,  and  are  able  to  get  a  hold  on  the 
disease,  which  has  become  used  to  the  first  method  of  treatment. 

(3)  If  a  short  course  of  treatment,  such  as  that  prescribed  above,  does 
not  promptly  relieve  the  cystitis,  a  specimen  of  urine  should  be  taken  by 
catheterization,  five  grains  of  chloral  added  to  the  ounce,  and  sent  to  the  near- 
est laboratory  for  examination  and  report.  I  suggest  this  here  for  the  con- 
venience of  practitioners  who  are  at  a  reasonable  distance  from  laboratory 
convenience  but  have  not  been  accustomed  to  using  them.  It  is  really  advis- 
able, as  a  rule,  to  take  this  step  at  the  outset,  as  it  will  save  the  occasional 
mistakes  in  treating  tubercular  cases  which  demand  surgical  treatment  from 
the  first,  and  are  never  much  benefited  by  mild  local  measures.  If,  with  rest, 
and  drugs,  and  diet,  and  instillations,  and  irrigations,  the  cystitis 
holds  on,  showing  no  signs  of  marked  improvement,  the  next  step  is 

(4)  Topical  Treatments. — It  is  one  of  the  healthy  signs  of  the  day 
that  many  general  practitioners  are  closely  enough  in  touch  with  the  various 
specialties  to  perform  certain  minor  surgical  operations,  to  operate  for  an 
urgent  appendicitis,  and  to  apply  treatments  to  the  throat  and  nose,  as  well 
as  to  undertake  a  variety  of  lesser  gynecological  procedures.  Such  men,  if 
familiar  with  the  use  of  the  head  mirror,  could  also  with  a  little  pains  ^dis- 
tinguish inflammatory  patches  in  the  bladder  through  my  open  air  cystoscope 
and  apply  topical  treatments  when  the  areas  involved  are  not  too  large.  To 
do  this  it  is  necessary  to  put  the  patient  in  the  knee-breast  position  and  to 
look  into  the  bladder  in  the  manner  described  in  the  section  on  examination 
of  the  bladder  (p.  552).  The  bladder,  expanded  with  air  by  posture,  is 
emptied  by  suction,  when  the  inflammatory  areas  are  seen  through  a  specu- 
lum two-fifths  of  an  inch  in  diameter.  It  is  equally  easy  to  use  an  applicator 
and  to  touch  the  affected  spots  with  a  two  to  five  per  cent  solution  of  silver 
nitrate.       Such  treatments  may  be  applied  every  three  to  five  days,  irriga- 

37 


562  CYSTITIS. 

tions  and  mild  instillatious  being  used  in  tlie  meantime.  Any  case  wliicli  fails 
to  improve  rapidly  ongiit  not  to  be  held  onto  indefinitely,  bnt  should  be  sent  to 
a  trustworthy  urological  specialist. 

(5)  Opsonic  Treatment. — The  profession  looks  with  eager  interest 
to-day  towards  the  opsonins  for  relief  from  chronic  infections.  I  do  not  know 
that  this  plan  has  as  yet  had  any  satisfactory  trial  in  bladder  disease.  The 
proper  course  for  opsonic  treatment  would  be  to  make  a  culture  from  the 
patient's  urine  and  to  inoculate  the  organism  causing  the  cystitis;  then  from 
this  to  make  a  vaccine  of  the  dead  organisms,  which  is  injected  as  a  toxine  to 
inhibit  the  activity  of  the  living  germs  in  the  vesical  tissues  by  stimulating 
the  production  of  antitoxines  in  the  patient's  body.  These  toxines  for  the  vari- 
ous organisms  can  be  secured  to-day  from  several  enterprising  firms  who  can 
keep  them  in  stock. 

(6)  Drainage  of  the  Bladder  by  the  Yagina. — This  method  of 
treatment  belongs  to  the  realm  of  the  surgeon,  and  it  is  not  my  purpose  to 
dwell  upon  the  operation  here,  further  than  to  indicate  that  the  drainage  may 
be  quickly  and  efliciently  made  by  putting  the  patient  in  the  knee-breast  posture 
and  then  opening  the  air-distended  bladder  through  the  vagina  by  pushing  a 
knife  through  the  septum  in  the  middle  line  between  the  internal  urethral 
orifice  and  the  neck  of  the  uterus.  Such  a  drain  should  be  kept  open  by  sew- 
ing the  vesical  to  the  vaginal  mucosa ;  unless  this  is  done,  the  wound  closes 
too  rapidly  to  be  of  much  service.  When  the  simple  drainage  does  not  suffice, 
irrigations  entering  through  the  urethra  and  running  out  by  the  drainage  open- 
ing may  be  kept  up  for  from  two  to  four  hours  each  day  (see  Fig.  157)  ;  or 
the  patient  with  the  drain  may  be  put  into  the  tub  for  several  hours  each  day. 
Under  such  treatment  marked  improvement  usually  takes  place  in  the  course 
of  a  few  months.  If  after  several  months  the  bladder  is  cleared  up  to  one  or 
two  red  and  bleeding  areas  the  surgeon  should  then  be  sought  to  excise  these 
by  a  suprapubic  operation.  By  one  or  another  of  these  methods  practically 
all  cases  of  cystitis,  except  tubercular  cystitis  in  the  last  stages,  are  amenable 
to  treatment.  I  know  of  no  disease,  however,  which  requires  more  constant 
exercise  of  good  judgment  in  devising  plans  of  treatment  and  in  persisting  in 
spite  of  many  discouragements  for  sometimes  as  much  as  several  years.  Some 
of  the  best  results  I  have  ever  seen  have  been  gained  by  treatments  extending 
over  three  or  four  years.  In  the  end,  however,  the  disease  was  cured,  health 
restored,  and  the  patient  delivered  from  a  distressing  malady.  The  result  in 
such  a  case  makes  all  the  labors  trifling  in  comparison  however  onerous  they 
may  have  seemed  at  the  time.  The  following  case  illustrates  how  much  may 
be  accomplished  by  sustained  effort  in  these  cases. 

Mrs.  E.  K.  B.,  age  thirty-nine,  April,  1907   (San.  'No.  2440). 

The  patient's  family  history  was  good  and  menstruation  had  always  been 
regular  and  painless.  She  had  been  married  fifteen  years,  but  had  never  had 
a  child;  she  dated  her  trouble  from  marriage.  About  fourteen  years  before 
coming  to  me,  she  began  to  have  a  severe  leucorrhea,   and  her  physician,  in 


LOCAL    TEEATMENT. 


563 


order  to  cure  this,  put  a  stick  of  silver  nitrate  into  the  urethra,  which  caused 
sloughing  of  the  entire  mucous  membrane.  This  caused  her  intense  suffering 
for  weeks  and  left  her  with  a  permanent  incontinence.  She  was  then  exam- 
ined by  a  distinguished  Chicago  surgeon,  who  told  her  that  the  sphincter  had 
been  entirely  destroyed.  She  had  had,  in  all,  about  eighteen  ojDerations  to 
cure  the  incontinence,  and  finally  had  a  spout-shaped  urethra  made  for  her. 
By  putting  a  pledget  of  cotton  underneath  this,  she  obtained  fair  control 
over  the  bladder,  nevertheless  there  was  a  considerable  irritation  in  it  as  well 
as  pain.      The  urine  contained  the    colon    bacillus    and  a  few  red  blood 


Fig.  157. 


-Method  of  Continttous  Ibrigations  of  the  Bladder  with  the  Patient  in  Bed  on  a 

Bedpak. 


cells.  An  examination  of  the  bladder  by  the  cystoscope  showed  a  normally 
shaped  bladder  of  normal  capacity.  The  mucosa  looked  fairly  normal,  except 
for  an  ulcerated  area  on  the  posterior  wall.  This  ulcerated  area  had  been 
treated  for  months  by  one  of  my  associates  with  local  applications  without 
relief.  I  opened  the  bladder  suprapubically,  examined  its  interior,  and  found 
that  there  was  only  one  place  of  disease,  namely,  an  ulcer  on  the  posterior 
wall,  which  was  three  centimetres  long  and  two  wide,     I  excised  this  ulcer. 


564 


CYSTITIS. 


sewed  up  the  bladder  wall  with  fine  catgut,  and  also  closed  the  suprapubic 
opening.  To  help  the  incontinence  I  used  a  paraffin  injection  under 
the  urethra.  The  patient  was  discharged  a  month  later  feeling  well,  with 
perfect  continence,  and  a  normal  looking  bladder.  This  was  one  of  those 
resistant  cases  which  yield  to  nothing  but  a  surgical  operation. 

A  simple  but  valuable  form  of  drainage  which  sometimes  works  admirably 
is  effected  by  the  insertion  of  a  self-retaining  catheter  through  the 
urethra.  Some  urethrse  will  tolerate  this  instrument  quite  well  and  for  a 
long  period  of  time.  The  catheter  serves  to  keep  the  bladder  emptied  and  at 
rest,  while  at  the  same  time  it  affords  a  way  of  irrigating  the  bladder  as  often 
as  may  be  necessary  without  the  distress  occasioned  by  catheterizing  the  patient 
every  time.  One  of  my  cases  did  well  in  this  way  under  a  constant  irrigation 
with  a  weak  boric  acid  solution.  This  was  affected  by  fastening  two  small 
rubber  catheters  together  with  rubber  cement  and  introducing  them  into  the 
bladder ;  they  were  held  in  place  by  a  perineal  pad  fastened  with  a  tape  around 
the  waist.  The  fluid  ran  in  slowly  through  one  catheter,  circulated  in  the 
bladder,  and  escaped  by  the  other.  This  avoided  the  making  of  a  vesico- 
vaginal fistula. 


CHAPTER    XXIII. 

FUNCTIONAL  NERVOUS   DISORDERS   MET  WITH   BY  THE   GYNECOLOGIST. 

Introduction,  p.  565.  Varieties  of  functional  neuroses:  Hysteria,  p.  566.  Neurasthenia,  p. 
567.  Hypochondria,  p.  568.  Psychasthenia,  p.  569.  Diagnosis  of  functional  neuroses, 
p.  572.     Prognosis,  p.  576.     Treatment,  p.  576. 

INTRODUCTION. 

Many  patients  who  complain  of  symptoms  referable  to  the  genito- 
urinary organs,  the  lower  abdomen,  or  the  back,  and  who  appeal  to 
the  gynecologist  for  aid,  are,  in  reality,  suffering  from  nervous  disorders 
and  require  treatment  directed  toward  the  nervous  system  rather  than  local 
therapy.  Unless  the  gynecologist  is  familiar  with  the  general  characteristics 
of  the  functional  neuroses,  he  will  often  be  led  astray  in  diagnosis,  and  will  be 
induced  to  institute  local  measures  of  treatment,  which,  by  focussing  the  atten- 
tion of  the  patient  upon  her  symptoms,  will  lead  to  their  perpetuation  rather 
than  to  their  amelioration.  If,  on  the  other  hand,  he  has  learned  how  to  un- 
mask the  functional  neurosis,  and,  having  attained  this  point,  to  direct  his 
treatment  toward  the  general  condition  of  the  patient,  he  will  often  score  suc- 
cesses quite  impossible  otherwise,  he  will  enhance  his  own  reputation,  and  in- 
crease greatly  the  value  of  his  service  in  the  community. 

In  the  functional  neuroses,  the  symptoms  presented  by  the  patient  may 
resemble  very  closely  those  of  organic  disease.  Frequent  and  painful 
micturition  may  excite  suspicion  of  the  existence  of  a  urethritis  or  a 
cystitis.  Pain  in  the  back  or  in  the  legs  may  suggest  some  uterine 
displacement.  Hyperesthesia  in  the  ovarian  region  may  make 
the  gynecologist  think  of  a  serious  ovarian  disease  ;  difficulty  in 
walking  may  suggest  disease  in  the  sacro-iliac  joints,  or  a  sciatica; 
nervous  disturbances  of  intestinal  origin  may  cause  fear  of  the  ex- 
istence of  organic  lesions  in  the  large  bowel  or  its  neighborhood. 
Dysmenorrhea  and  headaches  in  the  neurotic  are  often  considered  indi- 
cations for  dilatation  and  curettage.  Such  examples  might  be  multiplied 
almost  indefinitely,  and  every  working  gynecologist,  who  has  had  his  eyes  opened 
to  the  functional  disturbances  of  the  nervous  system,  is  familiar  with  the  mani- 
fold ways  in  which  the  symptoms  may  ape  those  presented  in  organic  disease. 
It  seems  worth  while,  therefore,  in  a  work  on  medical  gynecology,  to  direct 
attention  to  some  of  the    general    characteristics    of    the    functional 

565 


566       FUNCTIONAL    NEEVOUS    DISOKDEES    MET    WITH    BY    THE    GYXECOLOGIST. 

neuroses;  to  discuss  the  diagnosis  of  these  disorders  at  least  briefly,  paying 
special  attention  to  the  means  of  differentiating  them  from  certain  organic  affec- 
tions with  ^vhich  they  may  be  confounded;  and,  also,  finally  to  outline  the 
modern  mode  of  treatment  directed  toward  the  nervous  system  in  general, 
rather  than  toward  the  local  manifestations. 


VARIETIES    OF    FUNCTIONAL    NEUROSES. 

There  is  still  much  discussion  even  among  internists  as  to  the  proper 
classification  of  the  abnormal  neural  and  mental  phenomena  which  we  are  con- 
sidering, Xo  two  neurologists,  perhaps,  will  agTee  entirely  as  to  classification 
and  terminology.  The  various  functional  neuroses  seem  to  go  over  into 
each  other,  without  very  sharjD  limitation,  and  some  writers  suggest  that  we  do 
away  with  the  special  terms,  and  group  all  these  deviations  from  the  normal 
under  the  general  title  of  the  psyc hone u roses.  Those  who  have  had  much 
experience,  however,  in  the  study  of  these  disorders  are  able  to  recognize  certain 
toleral;)ly  definite  types,  Avhieh  recur  over  and  over  again,  and  for  convenience 
of  description  and  record  it  is  desirable  that  to  these  types  special  names  should 
be  given.  At  least  five  such  types  are  worthy  of  general  recogTiition,  namely, 
hysteria,  neurasthenia,  traumatic  neurosis,  hypochondria,  and 
psychasthenia.  For  a  full  description  of  the  phenomena  in  these  various 
types,  the  special  text-books  of  jSTeurology  and  Internal  Medicine  must  be  con- 
sulted. For  the  purpose  of  this  volume,  however,  a  few  brief  sentences  of 
definition  will  suffice. 

Hysteria,  contrary  to  a  widely  prevailing  opinion,  is  a  relatively  rare  disease. 
Xeurologists  now  understand  by  it  a  very  definite  type  of  nervous  disorder, 
and  eliminate  from  it  many  of  the  bizarre  nervous  symptoms  which,  to  the 
uninitiated,  imply  manifestations  of  hysteria.  The  most  striking  feature  of 
hysteria  is  the  extraordinary  susceptibility  of  the  patient  to  sug- 
gestion. The  disease  is  in  reality  a  mental  disease,  and  should  be  so 
regarded,  especially  in  treatment.  The  symptoms  which  the  patients  present 
are  both  bodily  and  mental,  but  the  mental  symptoms  predominate,  and  are  by 
far  the  most  important  to  understand.  It  is  common  to  divide  the  symptoms 
of  hysteria  into  two  great  groups,  the  so-called  stigmata,  and  the  so-called 
accidents    of   hysteria. 

By  the  stigmata  of  hysteria  are  meant  the  phenomena  of  the  disease 
which  tend  to  be  permanent.  These  include  the  hysterical  anesthesias,  the 
hysterical  amnesias,  the  hysterical  aboulias,  and  the  hysterical  alterations  of 
character. 

By  the  accidents  of  hysteria  are  meant  the  more  transitory  and 
episodal  phenomena  of  the  disorder.  Under  this  heading  of  accidents  are  in- 
cluded the  convulsive  crises,  the  paralyses,  the  contractures,  the  somnambulisms, 
and  the  deliria  which  may  occur. 

These  various  disturbances  of  function  met  with  in  hysteria  appear  to  be 


NEURASTHENIA.  567 

due  to  abnormal  ideas  in  the  minds  of  the  patients.  It  is  not  to  be  understood, 
however,  that  the  symptoms  are  not  real ;  nothing  can  possibly  be  more  real  to 
a  patient  than  the  symptoms  of  hysteria.  The  remarkable  fact  about  the  symp- 
toms is  that  they  can  be  produced  by  suggestion,  and  that  they  are  curable  by 
persuasion  (pithiatic  phenomena  in  the  sense  of  Babinski). 

Neurasthenia  is  a  much  more  common  affection  than  hysteria,  and  a  large 
number  of  patients  who  suffer  from  true  organic  disease  become  neurasthenic 
later  on  as  a  result  of  the  strain  upon  the  nervous  system,  due  to  the  organic 
affection.  Still  many  of  the  cases  develop  in  the  absence  of  a  demonstrable 
organic  disease,  owing  to  an  improper  mode  of  life  or  to  mental  or  physical  over- 
exertion ;  they  may  also  arise  from  faulty  nutrition,  or  from  the  effects  of  some 
nervous  shock,  or  prolonged  nervous  strain.  In  this  disease,  often  designated  as 
"  irritable  weakness,"  the  patients  are  frequently  more  excitable  than  normal, 
but  are  incapable  of  enduring  activity,  owing  to  the  tire  which  results  from 
the  exercise  of  almost  any  function.  The  symptoms  in  neurasthenia  are  both 
psychic  and  somatic.  They  vary  greatly,  but  certain  of  theni  recur  so  fre- 
quently that  they  deserve  special  mention.  Perhaps  the  most  constant  symp- 
tomatic feature  in  neurasthenia  is  fatigability.  The  patients  complain 
that  they  can  do  nothing  without  an  excessive  feeling  of  fatigue ;  if  they  walk, 
if  they  read,  if  they  try  to  follow  their  ordinary  occupation,  they  are  soon 
forced  to  desist  by  an  overwhelming  feeling  of  exhaustion.  Associated  with 
these  symptoms  of  fatigue,  headache  or  a  sense  of  pressure  in  the 
head,  pains  in  the  back,  and  sleeplessness  are  frequently  complained 
of.  It  is  not  surprising  that  patients  with  these  symptoms  should  become 
mentally  depressed,  and  the  mental  state  is  often  clearly  recognizable  in  the 
facial  expression. 

JSTeurasthenic  patients  very  frequently  complain  of  disturbances  of  the  di- 
gestive apparatus,  circulatory  apparatus,  and  the  genito-urinary 
apparatus.  The  symptoms  may  be  referred  to  one  of  these  systems  alone,  or 
to  two  or  more  of  them  simultaneously. 

Among  the  disturbances  of  the  digestive  apparatus  most  frequently 
complained  of  are  the  various  forms  of  indigestion;  the  neurasthenic  finds 
that  she  is  upset  by  certain  kinds  of  food ;  she  may  complain  of  a  heavy  feeling, 
of  soreness  in  the  region  of  the  stomach;  she  suffers  from  gaseous  eructations, 
and  from  distention  of  the  abdomen  with  gas ;  sometimes  she  is  nauseated,  and 
occasionally  asserts  that  the  eating  of  certain  articles  of  food  is  invariably  fol- 
lowed by  vomiting  or  regurgitation;  she  is  sure  that  she  has  an  idiosyncrasy 
for  milk,  or  for  vegetables,  or  for  some  one  of  the  varieties  of  food  which  enter 
into  the  daily  diet  of  the  normal  individual.  Constipation  is  very  frequent, 
and  many  of  these  patients  resort  constantly  to  laxatives,  purgatives,  or  enemata 
for  relief.     More  rarely  a  troublesome   diarrhea    is  complained  of. 

Among  the  circulatory  symptoms  presented  by  neurotic  patients  may 
be  mentioned  the  subjective  palpitation,  pain  or  anxiety  in  the  pre- 
cordial region,    with   throbbing   of  the    abdominal   aorta,    and  of  the 


568     ruNCTioisrAL  jSTekvous  disoedees  met  with  by  the  gyistecologist. 

peripheral  arteries.  Beating  in  the  head  is  a  symptom  which  is 
often  very  troublesome. 

Of  the  genito-urinary  disturbances  met  with  among  neurasthenics, 
frequent  or  painful  micturition,  imperative  micturition,  and 
nocturnal  micturition,  flattering  feelings  in  the  region  of  the 
bladder,  anomalies  of  the  menstrual  flow  (quantity,  quality,  pain), 
disturbances  of  sexual  desire  and  sense,  and  the  like,  are  not  un- 
usual. 

In  searching  for  the  etiology  in  these  neurasthenic  cases,  the  physician 
who  knows  how  to  ferret  it  out  will  be  surprised  to  find  how  often  the  cause 
lies  in  some  ethical  or  social  relation  which  has  been  responsible  for  a 
great  nervous  shock  or  strain.  This  fact  cannot  be  too  carefully  borne 
in  mind,  inasmuch  as  treatment  will  often  prove  unavailing  while  the  cause  is 
permitted  to  persist.  Another  fact  which  the  medical  practitioner  should  never 
forget  in  connection  with  neurotic  patients  is,  that  a  neurasthenia  producing 
symptoms  referable  to  the  genito-urinary,  the  circulatory,  or  the  di- 
gestive apparatus  maybe  due  to  the  existence  of  some  obscure  organic 
disease  in  some  other  part  of  the  body,  far  removed  perhaps  from  those  parts 
to  which  the  symptoms  most  complained  of  are  referred.  A  beginning  apical 
tuberculosis,  a  slowly  developing  brain  tumor,  an  uncorrected 
anomaly  of*  refraction,  a  persisting  sinusitis,  an  over-function 
of  the  thyroid  gland,  a  hypertrophic  osteo-arthritis  of  the  spine, 
or  a  flat-foot  may  be  the  organic  basis  of  nervous  symptoms  which  give  no 
clue  as  to  their  origin.  In  no  part  of  medicine,  therefore,  is  it  more  necessary 
to  make  a  thorough  systematic  routine  examination  of  the  whole  body  than  in 
patients  coming  to  us  with  neurasthenic  symptoms. 

The  condition  known  as  traumatic  neurosis  is  perhaps  not  so  often 
confused  with  gynecological  diseases  as  some  of  the  other  fimictional  neuroses. 
After  railroad  accidents  or  other  traumatisms,  however,  patients  may  develop 
symptoms,  the  result '  of  the  nervous  shock,  which  so  closely  resemble  disor- 
ders belonging  to  g^mecology  that  they  appeal  to  that  quarter  for  aid.  When  a 
thorough  gynecological  examination  reveals  the  absence  of  local  disease,  sufii- 
cient  to  account  for  the  symptoms  complained  of,  the  gynecologist  will  do  well 
to  seek  for  psychic  or  physical  trauma  which  might  give  rise  to  a  so-called 
traumatic  neurosis. 

Hypochondria  is  much  more  commonly  met  with  in  men  than  in  women,  but 
it  does  occur  in  the  latter,  and  the  g;>mecologist  should  be  familiar  with  the 
symptoms  which  hypochondriacal  patients  complain  of.  In  this  disorder  it  is 
the  nosophobia  or  fear  of  disease  which  is  especially  characteristic. 
Our  bodily  organs  are  supplied  with  sensory  nerve  fibres  along  which  impulses 
are  carried  centripetally  to  the  brain.  In  normal  life  these  impulses,  though 
of  the  gTcatest  importance  for  the  coordination  of  the  activities  of  the  body  and 
for  tlie  maintenance  of  normal  conditions  in  the  vegetative  and  psychic  life  of 
the  individual,  go  on  below  the  threshold  of  consciousness ;  we  are  totally  un- 


PSYCIIASTHENIA.  569 

aware  of  them.  In  hypocliondriacal  conditions  these  centripetal  impulses  no 
longer  remain  subconscious;  the  patient  begins  to  feel  abnormal  sensations  in 
various  parts  of  her  body  and  attempts  to  interpret  them.  Her  general  sense 
of  life  and  her  general  bodily  consciousness  are  different  from  what  they  were 
before.  She  complains  of  feeling  badly  and  describes  vague  distressing  sensa- 
tions which  keep  her  in  a  constant  state  of  discomfort ;  her  mood  alters  and 
she  may  become  very  much  depressed,  fearing  the  existence  of  serious  disease 
in  some  one  of  her  organs.  It  is  often  very  difficult  to  convince  the  hypochon- 
driacal patient  of  the  non-existence  of  demonstrable  organic  disease.  The  ab- 
normal sensations  and  the  continual  discomfort  are  such  real  things  in  the 
psychic  life  of  the  patient  that  any  amount  of  argumentation  on  the  part  of  the 
physician  frequently  fails  to  allay  the  patient's  fears. 

Psychasthenia. — A  mental  disorder  which  is  extremely  common,  but  which 
has  only  of  late  been  adequately  recognized,  is  the  condition  which  is  now 
designated  as  psychasthenia.  In  some  one  of  its  manifestations  it  is  per- 
haps the  commonest  functional  nervous  disorder  which  the  gynecologist  will 
meet  with.  Any  physician  who  sees  a  large  number  of  patients  each  day  is  sure 
to  have  among  them  several  who  present  psychasthenic  phenomena.  The 
psychasthenic  state  was  formerly  confused  with  hysteria  on  the  one 
hand,  and  with  neurasthenia  on  the  other,  but  since  the  very  careful  in- 
vestigations of  Pierre  Janet,  of  Paris,  medical  men  have  been  taught  how  to 
differentiate  this  state  from  the  others  to  which  it  is  more  or  less  closely  allied. 
The  severer  forms  of  the  affection  have  been  well  described  by  C.  L.  Dana,  of 
J^ew  York,  under  the  term  phrenasthenia,  and  English  writers,  notably 
Hack  Tuke  and  Mickle,  have  written  of  several  varieties  of  the  disease  under 
the  captions  of  "  imperative  ideas  "  and  "  mental  besetments."  In  this  coun- 
try a  large  number  of  psychasthenic  states  have  been  included  in  descriptions  of 
neurasthenia;  thus,  for  example,  the  various  phobias  described  by  Beard  are 
now  separated  from  neurasthenia  proper,  and  classified  under  the  heading  of 
psychasthenia.  Too  much  stress,  however,  must  not  be  laid  upon  classifica- 
tion. It  is  perhaps  impossible  to  draw  a  distinct  line  between  psychasthenia 
in  its  milder  forms,  and  some  of  the  neurasthenic  states,  and  even  hypo- 
chondria is  regarded  by  some  as  a  mental  state  which  may  occur  either  in 
neurasthenia  or  psychasthenia,  or  in  the  early  stages  of  the  more  out- 
spoken   psychoses. 

A  careful  study  of  Janet's  book,  entitled  "  Les  Obsessions  et  la  Psy- 
chasthenic," Paris,  1903,  can  be  heartily  recommended  to  any  one  who  desires 
to  familiarize  himself  with  the  main  features  of  this  remarkable  disorder. 
Psychasthenic  patients  suffer  almost  constantly  with  the  sense  of  incom- 
pleteness or  of  insufficiency,  from  disturbances  of  the  feelings 
of  reality,  and  from  other  symptoms  referable  to  the  lowering  of  the 
so-called  psychological  tension.  It  is  probably  owing  to  these  funda- 
mental disturbances  that  the  other  phenomena,  which  are  clinically,  perhaps, 
more   characteristic   of  the   malady,    develop,   namely,   the   obsessions,   the 


570        FUXCTIO:srAL    jSTEKYOUS    DISOEDEES    met    "WITH    BY    THE    GYNECOLOGIST. 

pseudo-liallucinatioiis,  the  impulses,  the  mental  manias,  the 
tics,  the  forced  agitations,  the  fears,  the  anxiety  conditions,  the 
sense  of  strangeness  and  unrealitv,  the  phenomena  of  deper- 
sonalization,   and  the  like. 

The  imperative  ideas  or  obsessions  presented  by  psychasthenic  pa- 
tients differ  much  in  content ;  the  idea  has  a  permanence,  entirely  out  of 
accord  Tvith  its  importance  and  its  practical  utility ;  it  comes  up  into  the  head 
of  the  patient  over  and  over  again  in  spite  of  herself,  and  do  what  she  vill, 
she  cannot  rid  herself  of  it.  Sometimes  it  is  an  idea  of  sacrilege,  sometimes 
an  idea  of  crime,  sometimes  an  idea  of  shame  regarding  herself  or  her  body, 
or,  perhaps,  an  idea  of  incurable  disease.  Every  gynecologist  is  familiar  with 
the  patient  who,  in  spite  of  repeated  assurances  to  the  contrary,  is  convinced 
that  she  has  some  serious  disorder  of  her  ovary,  of  her  uterus,  of  her  bladder, 
or  of  her  kidney;  the  whole  intellectual  interest  of  the  patient  centres  in  her 
health,  or  in  the  disorder  of  that  health  which  she  assumes  does  exist.  Very 
frequently  some  painful  thought  is  associated  with  some  normal  process  in  the 
body ;  indescribable  anxiety  is  associated  with  the  function  of  micturition,  or  of 
defecation,  for  example.  Other  patients  have  a  sense  of  shame  connected  with 
their  bodily  appearance;  they  are  too  fat,  or  they  are  imperfectly  developed  in 
some  part,  or  they  complain  of  some  peculiar  movement  of  the  body,  or  of 
abnormal  blushing,  or  of  persistent  pimples,  or  of  abdominal  distention.  The 
most  bizarre  idea  may  become  focal  in  consciousness,  and  despite  the  greatest 
effort  to  become  marginal,  remain  focal.  It  is  curious  that  most  of  these  fixed 
ideas  are  associated  in  a  certain  degree  with  self-accusation.  Indeed  it  is 
the  scrupulosity  of  the  psychasthenic  patient  which  often  characterizes  her 
especially. 

When  the  patients  complain  of  abnormal  impulses,  the  impulses  are 
nearly  always  directed  to  the  performance  of  some  evil  deed,  and  the  acts  which 
they  think  themselves  forced  to  perform  are  extreme  in  nature;  the  patients 
describe  them  as  most  sacrilegious,  most  criminal,  most  dangerous,  or  most 
odious.  As  a  matter  of  fact  they  rarely  yield  to  the  impulses  which  they  say 
dominate  them. 

These  imperative  ideas  and  impulses  are  present  in  the  most  outspoken  cases 
of  psych  asthenia.  It  is  the  less  outspoken  cases,  with  milder  symptoms, 
which  are  more  likely  to  be  met  with  by  the  gynecologist,  and  which,  at  first, 
may  puzzle  him. 

The  feelings  of  insufficiency  and  incompleteness  characteristic 
of  the  milder  psychasthenic  states  are  those  most  important  to  recognize; 
too  little  attention  is  paid  to  them,  because  they  are  feelings  to  which  even  the 
normal  mind  is  occasionally  subject.  The  incompleteness  described  by  the  pa- 
tient may  refer  to  her  actions,  to  her  intellectual  processes,  to  her  emotions,  or 
to  her  personality.  A  woman  presenting  gynecological  symptoms  may  in  paren- 
thesis tell  us  that  she  has  noted  an  increasing  difficulty  in  action,  or  that  she 
feels  that  all  effort  is  useless,  or  that  she  is  no  longer  a  capable  woman,  that 


PSYCHASTHENIA.  571 

she  is  troubled  about  making  up  her  mind  about  things,  that  she  is  doubtful 
or  hesitates  before  doing  things,  that  she  is  discontented  with  life,  that  she 
suffers  from  being  over-humble,  or  that  she  is  in  a  state  of  revolt  or  resentment 
regarding  conditions  in  which  she  finds  herself  placed.  Other  women  complain 
that  they  have  noticed  a  growing  indifference  to  things  in  which  they  were  for- 
merly interested,  and  in  which  they  know  they  should  still  have  a  lively  interest. 
A  persistent  sense  of  boredom  is  not  an  infrequent  complaint  in  the  gynecological 
consultation  room.  Other  patients  suffer  from  an  indefinable  anxiety  or  dis- 
quiet ;  women  frequently  say  that,  in  order  to  relieve  their  minds  of  their  local 
troubles,  they  are  compelled  to  resort  to  various  diversions  or  exciting  occu- 
pations. 

Besides  these  subjective  complaints  which  the  women  themselves  report, 
their  husbands  or  friends  may  also  describe  to  the  physician  observations  which 
they  have  made,  and  which  are  quite  in  accord  with  the  subjective  complaints 
of  these  patients.  The  daily  observation  of  the  husband,  if  he  have  his  eyes 
open  to  these  modifications  of  psychic  function,  may  have  put  in  evidence  cer- 
tain disturbances  of  the  will,  of  the  intellect,  or  the  emotions  of  his  wife ;  he 
may  have  noticed  a  growing  indolence,  an  increasing  lack  of  resolution,  a  cor- 
responding feebleness  of  effort,  the  quick  development  of  fatigue  on  exertion, 
a  dislike  for  new  surroundings  or  occupation,  a  preternatural  social  timidity, 
an  abnormal  inertia,  or  even  outspoken  crises  of  exhaustion;  or  he  may  have 
noticed  that  his  wife  has  gradually  become  more  forgetful,  or  that  the  memory 
is  slower  than  it  formerly  was,  or  that  she  pays  less  attention  to  what  is  said 
to  her,  often  appearing  distrait  and  wrapped  in  revery.  On  the  emotional  side, 
he  may  have  observed  a  real  indifference  which  is  unnatural,  an  increasing  de- 
pression of  spirits  sometimes  reaching  actual  melancholy,  an  exaggerated  emo- 
tional reaction  to  the  ordinary  occurrences  of  life,  a  desire  of  being  controlled, 
or  an  abnormal  desire  to  control  others ;  an  inordinate  craving  for  affection,  or 
for  the  expression  of  her  own  affection. 

One  of  the  most  characteristic  disturbances  to  which  these  psychasthenic 
women  are  subject  concerns  the  so-called  sense  of  reality.  In  the  first 
clinical  conversation  with  such  a  patient  she  may  volunteer  the  statement  that 
things  seem  unnatural  to  her,  that  everything  looks  hazy,  or  as  though  a  veil 
were  drawn  between  her  and  the  external  objects.  In  other  patients,  while 
things  outside  themselves  appear  natural  to  them,  a  feeling  of  some  change  in 
their  own  bodies  is  complained  of;  they  realize  that  they  are  different  from 
what  they  formerly  were ;  they  state  that  they  are  only  half  alive,  or  that  they 
feel  as  though  they  were  dead  or  dying,  or  as  though  the  mind  were  separate 
from  the  body.  Examples  such  as  these  will  enable  the  physician  to  recog-nize 
other  similar  complaints  which  belong  in  the  same  category. 

A  word  as  to  some  of  the  forms  of  mental  manias  presented  by  the  more 
severe  types  of  psychasthenic  patients  may  here  be  in  place.  Some  of  these 
patients  are  tormented  by  an  eternal  questioning  concerning  the  nature 
of  things,  or  concerning  anything  which  they  happen  to  think  about;  or  they 


572        FUNCTIONAL    NEKVOUS    DISORDERS    MET    WITH    BY    THE    GYNECOLOGIST. 

have  manias  of  liesitation  or  deliberation  ;  in  others  the  need  of 
precision  is  overwhelming;  if  any  little  thing  is  out  of  place  in  their  houses, 
they  suffer  intensely,  and  make  others  suffer  for  it.  Others  have  troubles  in 
the  use  of  certain  numbers,  especially  the  number  seven  or  the  number 
thirteen;  still  others  cannot  pass  certain  objects  without  touching 
them  ;  some  are  compelled  always  to  pay  attention  to  a  whole 
series  of  precautions  before  undertaking  anything,  and  some 
state  that  they  are  continually  besieged  with  premonitions  of  im- 
pending   occurrences. 

Among  the  emotional  agitations  presented  by  the  psychasthenic  pa- 
tients, various  sorts  are  common:  fear  of  disease,  fear  of  going  insane,  fear  of 
places,  fear  of  animals,  fear  of  people,  fear  of  anything. 

It  is  to  be  remembered,  in  psychasthenia  especially,  that  the  symptoms  tend 
to  be  periodic  in  course.  A  psychasthenic  woman  has,  in  the  majority  of  in- 
stances, inherited  a  pathological  nervous  system,  so  that  anything  which  lowers 
the  general  vitality  will  tend  to  give  rise  to  a  psychasthenic  state,  and  this  state 
will  persist  until  the  general  health  is  again  improved  enough  to  raise  the  level 
of  j)sychasthenic  tension  sufficiently  high  to  overcome  the  symptoms.  It  is  not 
at  all  uncommon  in  such  patients  to  find  that  they  have  suffered  similarly  for 
shorter  or  longer  periods  several  times  before,  at  intervals  of  months  or  years. 
Some  see  in  this  the  possible  relation  of  psychasthenic  states  to  the  more  severe 
psychoses  of  well-known  circular  type.  However  this  may  be,  the  periodicity 
of  psychasthenic  manifestations  is  a  fact  which  should  always  be  kept  in  mind 
in  connection  with  diagnosis  and  prognosis. 

In  addition  to  the  various  types  of  functional  disorder  which  are  more  or 
less  characteristic,  and  which  have  been  briefly  described  above,  the  gynecologist 
will  often  meet  with  slight  nervous  manifestations  which  he  may  find 
difficult  to  classify.  Some  of  his  patients,  for  instance,  may  complain  of  a 
tendency  to  hurry,  to  worry,  or  to  be  abnormally  irritable ;  others  will  ask  for 
relief  from  a  morbid  self-consciousness,  or  an  abnormal  personal  sensitiveness, 
or  an  indefinable  state  of  apprehension;  the  husband,  in  turn,  may  confiden- 
tially appeal  to  the  physician  to  notice  a  habit  of  contradiction  in  his  wife,  or 
a  resentful  disposition. 

In  such  cases,  the  physician  will  do  well  to  be  on  his  guard,  and  seek  for 
other  less  manifest  abnormal  neural  symptoms ;  here  a  thorough  psychic  inquiry 
is  important,  and  the  more  the  gynecologist  trains  himself  in  the  technic  of 
psychic  methods  of  inquiry,  the  greater  will  be  his  success  in  the  management 
of  such  cases. 

DIAGNOSIS    OF    THE    FUNCTIONAL    NEUROSES. 

Mistakes  are  perhaps  more  frequently  made  in  connection  with  the  diag- 
nosis of  the  functional  neuroses  than  in  any  other  part  of  medicine.  In  thou- 
sands of  women  the  diagnosis  is  undoubtedly  entirely  overlooked,  and  these 
patients  are  transferred  from  specialist  to  specialist,  who  treat  their  reflexes 


DIAGNOSIS.  '  573 

and  sometimes  do  more  liarm  than  good  by  concentrating  tlie  attention  of  tlie 
patient  npon  lier  symptoms  by  making  local  applications.  On  the  other  hand, 
those  who  are  impressed  with  the  importance  of  the  psychic  and  nervous  symp- 
toms, unless  they  are  very  careful  in  the  exclusion  of  organic  disease,  may, 
through  their  efforts  to  treat  the  general  condition,  overlook  an  important  local 
cause  which  has  been  responsible  for  the  origin  of  the  nervous  symptoms,  and 
which  will  cause  them  to  persist  until  it  is  removed.  It  is,  therefore,  desirable 
that  the  gynecologist,  the  general  internist,  and  the  neurologist 
should  cooperate  in  the  study  of  cases  which  present  a  combination  of  gyn- 
ecological complaints  with  general  nervous  manifestations.  If,  on  the  one  hand, 
the  internist  would  consult  the  gynecologist  more  frequently,  in  order 
that  he  may  be  sure  of  the  presence  or  absence  of  a  gynecological  lesion;  and 
if,  on  the  other  hand,  the  gynecologist  would  refer  more  of  his  patients  to 
the  neurologist  and  the  general  internist  for  a  thorough  systematic 
study  and  report,  fewer  mistakes  would  be  made.  The  great  difficulty  of  the 
internist  is  to  find  a  gynecologist  to  whom  he  can  refer  patients  for  ex- 
amination, who  v/ill  not  be  too  much  impressed  with  slight  local  gynecological 
lesions,  and  who  will  be  broad-minded  enough  to  understand  that  not  every 
gynecological  disturbance  in  a  patient  presenting  general  nervous  symptoms 
deserves  radical  local  treatment;  and  the  difficulty  of  the  gynecologist,  in 
his  turn,  is  to  find  a  neurologist  or  an  internist  whom  he  can  trust  to 
pass  judgment  upon  the  relative  importance  of  the  general  manifestations  pre- 
sented by  patients  who  have  applied  to  the  gynecologist  for  aid.  ISTevertheless, 
it  is  only  through  the  hearty  cooperation  of  the  internist  and  the  various  special- 
ists that  the  highest  success  can  be  obtained  in  the  treatment  of  patients,  and 
every  physician  who,  by  his  broadness  and  soundness  of  judgment,  contributes 
to  the  growth  of  mutual  confidence  among  medical  practitioners  in  this  respect 
will  be  of  great  service  in  the  community  in  which  he  lives. 

It  will  be  obvious  from  what  has  been  said  above  in  regard  to  the  symp- 
tomatology, that  it  is  the  consideration  of  the  woman  as  a  whole  which  is 
all  important  in  these  cases.  A  narrow  specialization  is  disastrous,  and  yet  the 
general  examination  must  avail  itself  of  the  most  modern  refinements  of  diag- 
nosis in  all  the  special  branches.  Every  practitioner  then  should  arrange  some 
cooperative  organization  by  means  of  which  he  will  be  able  to  provide  himself 
with  all  the  data  necessary  for  the  exclusion  of  organic  disease,  and  the  deter- 
mination of  the  exact  degree  and  significance  of  existing  organic  disease  in  all 
parts  of  the  body. 

A  careful  consideration  of  the  individual  symptoms  presented,  and  the 
grouping  of  these  symptoms,  will  permit  a  decision  as  to  the  particular  form 
of  nervous  or  mental  malady  with  which  one  is  dealing.  The  most  important 
clues  to  the  three  main  types  of  functional  disorder  are  as  follows:  For 
hysteria,  the  suggestibility;  for  neurasthenia,  the  fatigability;  and  for 
psychasthenia,  the  sense  of  incompleteness  and  insufficiency,  the  indecision, 
the  interrogations,  the  doubts,  and  the  fears. 


574       FUNCTIONAL    NERVOUS    DISOEDEES    MET    WITH    BY    THE    GYNECOLOGIST. 

There  are  certain  forms  of  organic  disease  that  present  symptoms  which 
practitioners  too  often  regard  as  entirely  functional  in  origin.  It  will  be 
desirable  to  refer  to  some  of  these  in  detail,  bearing  in  mind,  of  course,  the 
special  needs  of  the  gynecological  practitioner. 

A  beginning  tabes,  though  less  common  in  women  than  in  men,  may 
give  rise  to  local  symptoms  whose  significance  the  physician  may  underesti- 
mate. A  difficulty  in  passing  urine,  a  complaint  of  rectal,  vaginal,  or  vesical 
pain,  especially  if  it  occur  in  the  form  of  paroxysmal  attacks  or  crises,  a 
marked  change  in  the  sexual  desire  or  sense,  should  make  one  suspicious  of 
the  existence  of  degeneration  of  the  posterior  funiculi  of  the  spinal  cord,  and 
should  lead  one  to  make  at  least  an  examination  of  the  state  of  the  general 
bodily  sensation  and  the  reflexes,  especially  the  pupillary  and  patellar  reac- 
tions. Should  any  anomaly  be  found,  the  patient  should  be  subjected  to  a 
thorough  routine  neurological  study,  to  determine  the  presence  or  absence  of 
a  latent  locomotor  ataxia. 

More  rarely,  lesions  of  the  cauda  equina  or  conus  medullaris 
may  give  rise  to  genito-urinary  or  rectal  symptoms  with  which  the  gynecol- 
ogist must  be  familiar.  An  incontinence  of  urine  or  feces,  or  an  anesthesia 
in  the  region  of  the  vulva  or  mons  veneris,  should  put  the  jDhysician  on  his 
guard  and  make  him  test  the  Achilles  reflex  as  well  as  search  for  other  evi- 
dences of  organic  change  in  the  lower  part  of  the  spinal  cord  or  spinal  canal. 

An  osteo-arthritis  of  the  lower  portion  of  the  vertebral  col- 
Timn,  or  the  sacrum,  or  of  the  sacro-iliac  joints  may  give  rise  to 
symptoms  which  lead  the  patient  to  the  gynecologist.  Pain  in  the  small  of 
the  back,  or  in  the  sacrum,  or  sacro-iliac  organs,  or  down  the  backs  of  the 
thighs  and  legs  may  be  associated  with  disturbances  of  locomotion  and  with 
anomalies  of  position  of  the  spine  or  pelvis.  Here  a  careful  physical  exam- 
ination, associated  with  an  X-ray  iphotogTaph  of  the  lower  vertebral  column 
and  of  the  sacro-iliac  joints  should  clear  up  the  diagnosis. 

Another  disorder  to  which  attention  has  recently  been  drawn,  especially  by 
the  orthopedic  surgeon,  Goldthwait,  of  Boston,  is  the  relaxation  of  the 
sacro-iliac  joints  which  so  frequently  occurs  in  women,  especially  at 
middle  life,  and  in  those  who  are  overnourished,  or  who,  for  one  reason  or 
another,  have  been  compelled  to  remain  in  bed  for  a  considerable  period  of 
time  (repeated  pregnancies,  gynecological  operations,  rest  cures,  etc.).  By 
means  of  the  so-called  sacro-iliac  test,  the  attitude  assumed,  the  history  of  the 
case,  and  the  exclusion  of  other  diseases,  the  g-j^Tiecologist  should  learn  to  recog- 
nize these  cases  and  refer  them  to  the  orthopedist  for  mechanical  treatment 
(see  Chap.  IX). 

Mucous  colitis  is  a  manifestation  too  often  maltreated  by  the  gyne- 
cologist and  by  the  gastro-enterological  practitioner.  Sometimes  a  mucous 
colitis  is  undoubtedly  due  to  irritation  from  a  misplaced  uterus,  or  perhaps  to 
reflex  irritation,  but  in  the  majority  of  cases  it  should  be  looked  upon  as  a 
nervous  disease  and  treated  by  measures  directed  toward  the  improvement  of 


DiAGisrosis.  575 

the  general  health  rather  than  by  local  applications.  It  is  not  uncommon  to 
see  cases  treated  for  months  and  years  by  intestinal  lavage,  oil  enemata,  astrin- 
gents, or  other  local  measures  with  progressive  deterioration  of  the  patient. 
In  most  of  these  cases  the  complete  cessation  of  local  treatment  is  advisable, 
and  the  patient,  if  put  to  bed,  isolated  from  her  friends,  overfed,  and  suitably 
encouraged,  will  get  well. 

A  word  should  perhaps  be  said  with  regard  to  the  danger  of  confusing  the 
symptoms  of  an  early  multiple  sclerosis  with  hysteria  or  with  other 
functional  neurological  manifestations.  This  is  a  mistake  which  the  best  neu- 
rologists dread,  and  where  there  is  the  least  doubt,  a  complete  routine  neuro- 
logical investigation  should  be  resorted  to  before  drawing  the  final  inferences 
regarding  the  diagnosis.  Of  course,  in  the  outspoken  cases  with  scanning 
speech,  nystagmus,  intention  tremor,  and  pallor  of  the  optic  papillae,  there 
can  be  no  doubt,  but  in  cases  in  which  the  classical  symptoms  are  not  in  evi- 
dence, there  is  great  danger  of  overlooking  this  serious  condition. 

Hyperthyroidism  is  a  condition  often  associated  with  nervous  dis- 
turbances ;  it  is  far  more  common  than  is  realized  by  the  average  family  prac- 
titioner. ISTot  infrequently  it  accompanies  diseases  of  the  genito-urinary  organs, 
and  when  it  does  so,  it  may  in  reality  be  responsible  for  the  symptoms  which 
the  patient  presents,  rather  than  the  local  gynecological  lesion  which  has  been 
recognized,  and  for  the  treatment  of  which  the  patient  has  come  to  the  physi- 
cian. Periuterine  inflammation  has  long  been  kno^^^l  to  be  frequently  asso- 
ciated with  symptoms  of  hyperthyroidism,  and  Freund's  report  on  the  subject 
is  an  admirable  statement  of  the  facts.  As  Albert  Kocher  has  pointed  out, 
too,  a  diminution  of  the  menstrual  flow  is  very  common  in  patients  suffering 
even  from  the  milder  forms  of  Graves'  disease.  In  a  patient  presenting 
obscure  nervous  symptoms,  especially  one  complaining  of  apprehension  and 
indefinable  anxiety  without  apparent  cause,  the  physician  should  make  the 
tests  necessary  to  determine  whether  or  not  a  hyperthyreosis  exists ;  if  a  tachy- 
cardia (or  better  pycnocardia)  exist  continually;  if  there  be  a  struma,  espe- 
cially if  it  be  vascular  in  nature,  pulsating  visibly,  and  giving  a  thrill  to  the 
palpating  finger,  and  especially  if  bruits  are  audible  over  the  point  of  entrance 
of  the  thyroid  arteries  into  the  thyroid  gland,  the  diagnosis  may  be  regarded 
as  certain,  and  the  patient  should  be  referred  to  a  surgeon  skilled  in  the  tech- 
nic  of  partial  thyroid  extirpation  and  arterial  ligature.  Rapid  tremor  of  the 
fingers  in  this  disease  is  exceedingly  characteristic,  and  is  a  test  which  can  be 
applied  in  a  moment,  often  pointing  the  way  to  the  diagnosis.  A  familiarity 
with  some  of  the  eye-signs  in  patients  with  hyperthyroidism  is  also  a  great 
help,  and  often  keeps  the  physician  from  overlooking  the  affection.  By  ask- 
ing the  patient  to  follow  the  finger  as  it  is  gradually  moved  downward,  it  is 
possible  to  make  out  whether  or  not  the  eyeball  runs  ahead  of  the  eyelid,  so 
that  the  white  sclera  shows  between  the  cornea  and  the  upper  lid  (von  Graefe's 
sign).  Or,  if  the  patient  is  asked  to  look  at  the  ceiling,  and  then  at  the  end 
of  her  nose,  he  can  determine  whether  or  not  there  is  tendency  to  inability  to 


576       I"UNCTION"AL    NERVOUS    DISORDERS    MET    WITH    BY    THE    GYNECOLOGIST. 

iiiaintain  the  condition  of  convergence  (Mobins's  sign).  Or,  be  may  notice 
whether  or  not  the  visnal  aperture  is  much  widened,  and  if  involuntary  wink- 
ing be  lessened  or  incomplete  (von  Stcllwag'g  sigTi).  Of  course,  when  there 
is  exophthalmos  it  is  the  most  striking  and  characteristic  sign  and  recognizable 
even  by  the  laity,  but  it  should  not  be  forgotten  that  marked  protrusion  of  the. 
eyeballs  is  absent  in  perhaps  two-thirds  of  the  cases  of  hyperthyroidism. 

PROGNOSIS. 

The  jDatients  and  the  patients'  friends  are  always  anxious  to  know  whether 
or  not  the  condition  they  come  to  be  treated  for  is  curable,  and  here  long 
experience  in  dealing  with  the  functional  neuroses  is  necessary  before  that 
matured  power  of  judgment  can  be  gained  which  will  permit  the  physician  to 
speak  to  the  patient  with  anything  like  accuracy  as  to  the  outcome  which  may 
Le  expected.  With  the  modern  studies  of  the  psychoneuroses,  new  hope  can  be 
held  out  to  these  patients.  Many  women  who  formerly  would  have  been  doomed 
to  a  lifetime  of  incapacity  and  non-productiveness  can  now  be  restored  to  very 
good  health  and  be  made  useful  members  of  the  community. 

In  the  treatment  of  the  milder  forms  of  hysteria  and  psychasthenia,  and 
especially  in  the  treatment  of  neurasthenia,  in  all  forms  except  those  in  which 
there  is  a  pronounced  hereditary  taint,  the  results  are  very  gTatifying.  In 
the  gTaver  forms  of  hysteria,  in  the  severer  forms  of  psychasthenia,  and  in 
outspoken  cases  of  hypochondriasis,  we  have  to  deal  with  mental  disorders 
which  often  tax  all  the  resources  of  the  physician,  and  which  sometimes  the 
best-directed  efforts  known  to  modern  neurology  and  psychiatry  fail  to  cure. 
In  nearly  all  cases,  however,  even  the  most  severe,  it  is  possible  to  get  great 
relief,  provided  the  psychic  factor  is  clearly  recognized,  and  the  proper  methods 
of  treatment,  especially  the  resources  of  psychotherapy,  are  applied. 

TREATMENT. 

For  a  full  discussion  of  the  treatment  of  these  disorders  works  upon  ISTeu- 
rology.  Psychiatry,  and  Internal  ]\Iedicine  must  be  consulted,  but  the  general 
principles  will  be  briefly  referred  to  here. 

In  the  first  place  it  cannot  be  too  strongly  emphasized  that  any  routine 
treatment  of  these  cases  is  likely  to  be  harmful.  In  no  part  of 
medicine  is  a  definite  individualization  of  the  therapy  more  necessary.  Great 
harm  is  done  in  the  routine  application  of  the  so-called  "  rest  cure,"  and  rather 
than  recommending  a  systematic  routine  it  would  be  nearer  the  truth  to  state 
that  no  two  nervous  patients  need  the  same  treatment. 

Preceding  all  treatment  there  should  be  established,  as  has 
already  been  said,  a  very  exact  anatomical,  functional,  and  etiological 
diagnosis,  and  the  diagnostic  study  should  have  been  extended  to  all  parts 
of  the  body  of  the  patient.     Only  by  strict  adherence  to  this  rule  can  serious 


REST    CURE.  577 

mistakes  be  avoided,  and  medicine  kept  from  the  pitfalls  which  beset  the  work 
of  quacks  and  irregular  healers. 

Having  formed  a  judgment  as  to  the  actual  condition  which  exists,  the 
patient  should  be  frankly  told  the  results  of  the  study  and  the  opinions  of 
the  physician  as  to  the  nature  of  her  disease,  and  the  rationale  of  the  treatment 
to  be  followed. 

If  a  cause  of  the  disorder  has  been  made  out  and  found  to  be  still  persist- 
ing, the  first  indication  in  treatment  is,  of  course,  its  removal,  and  the  physi- 
cian who  bears  this  fact  in  mind  will  be  very  much  surprised  to  find  how 
often  by  a  change  of  environment,  or  by  intervention  in  some  social  relation, 
the  whole  clinical  picture  can  be  speedily  altered.  Again,  if  some  organic 
disease  be  found  to  exist,  and  the  physician  conscientiously  feels  convinced 
that  it  is  responsible  for  the  nervous  symptoms,  treatment  should  be  directed 
toward  this,  either  at  once  or  after  such  preliminary  preparation  as  seems 
necessary.  An  incipient  tuberculosis,  an  osteo-arthritis,  an  eye- 
muscle  anomaly,  a  displaced  uterus,  bleeding  hemorrhoids,  or 
a  gonococcal  trigonitis  will  receive  its  appropriate  attention,  and  after 
its  indications  have  been  met,  the  health  of  the  patient  can  be  built  up  by  gen- 
eral reconstructive  measures,  and  then  the  nervous  symptoms  may  be  expected 
to  disappear. 

In  cases  in  which  the  condition  is  predominantly  a  psych oneurosis, 
the  gynecologist  may  undertake  the  treatment  himself  if  he  is  interested  in 
this  work  and  has  the  facilities  for  caring  for  psychoneurotic  patients;  or  he 
may  refer  the  patient  to  an  internist  or  neurologist  who  devotes  his 
attention  especially  to  such  treatment. 

The  best  means  of  combating  the  psychone ureses  known  to  medical 
men  at  present,  consist  in  rest,  isolation,  the  improvement  of  nutri- 
tion, and  psychotherapy.  In  addition  to  these  main  therapeutic  instru- 
ments, certain  adjuvant  measures  are  more  or  less  helpful,  such  as  the  use  of 
electricity,    drugs,    etc.,  especially  in  combating  some  of  the  symptoms. 

Rest  may  be  prescribed  in  various  ways,  though  usually  physicians  apply 
.the  well-known  "  rest  cure  "  of  Weir  Mitchell.  When  this  treatment  is  adopted, 
it  is  common  to  keep  the  patient  on  her  back  in  bed  completely  at  rest,  phys- 
ically and  mentally,  for  a  period  of  from  four  to  six  weeks,  after  which  she 
is  gradually  permitted  to  return  to  various  physical  and  mental  activities.  A 
prolonged  rest  of  this  sort  is  especially  helpful  in  cases  of  neurasthenia 
and  in  psychasthenic  states,  associated  with  emaciation.  The  most  bril- 
liant results  are  obtained  in  the  patients  who  have  suffered  from  nervous  dis- 
turbances of  digestion  and  who  have  reduced  their  diet  gradually  until  they 
have  gotten  into  a  state  in  which  they  are  eating  far  less  than  is  required  to 
nourish  them.  Many  of  these  patients  have  had  the  erroneous  idea  that  they 
should  exercise  more  as  their  emaciation  progressed;  some  one  has  told  them 
to  keep  up  strenuous  physical  exercise,  and  not  a  few  of  them  who  apply  for 
treatment  will  be  found  to  be  following  daily  some  rigidly  prescribed  system 
38 


578       FUXCTIOXAL    IVEEVOUS    DISOEDEES    MET    WITH    BY    THE    GYNECOLOGIST. 

of  gymnastics,  despite  the  miserable  state  of  their  nutrition.  It  is  very  impor- 
tant to  remember,  however,  that  not  every  nervous  patient  needs  rest  in  bed. 
Some  patients  do  badly  in  bed,  and  mnch  experience  and  medical  tact  is  neces- 
sary to  decide  when  this  treatment  should  be  tried  and  when  it  should  be 
avoided.  Some  of  the  severer  jjsychasthenic  cases  especially  do  badly  in  bed, 
and  though  in  the  treatment  of  the  obese  nervous  patient  a  short  stay  in  bed 
may  be  desirable  at  the  beginning  of  the  treatment,  any  prolonged  sojourn  in 
the  recumbent  position  is  harmful  for  her. 

In  all  the  severer  forms  of  the  psychonenroses  (but  of  course  not 
in  the  milder  forms  of  the  disease)  isolation  of  the  patient  is  abso- 
lutely necessary  if  the  best  results  are  to  be  obtained.  This  is 
one  of  the  most  important  features  of  the  cure  as  it  was  carried  out  by  Weir 
]\Iitchell,  and  it  is  a  feature  which  unfortunately  has  been  honored  more  in 
the  breach  than  in  the  observance  by  those  who  have  attempted  to  imitate 
Mitchell  in  his  management  of  nervous  patients.  It  is  not  always  easy  to  get 
the  consent  of  patients  to  submit  themselves  to  complete  isolation  from  family 
and  friends.  Even  when  the  patient  and  her  friends  consent  to  isolation,  too 
frequently  the  physician  and  the  nurse  do  not  maintain  her  in  the  necessary 
degree  of  separation.  For  instance,  many  medical  men  have  made  the  error 
of  attempting  to  isolate  neiwous  women  in  bedrooms  in  their  own  houses.  This 
is  almost  invariably  unsuccessful,  and  it  is,  as  a  rule,  better  not  to  make  any 
pretence  of  isolation  at  all,  than  to  try  to  carry  it  out  in  this  ineffectual  way. 
The  patient  and  her  friends  mean  to  observe  isolation  when  they  promise  to 
do  so  in  the  patient's  own  house,  but  they  almost  always  find  it  impossible 
to  adhere  to  the  rules.  It  is,  therefore,  very  desirable  when  isolation  is  prac- 
tised, to  remove  the  patient  to  an  institution  (sanitarium,  hospital,  or  private 
house  specially  arranged  for  the  purpose)  in  which  she  will  see  no  one  except 
her  j)hysician  and  nurses,  and  in  which  she  will  not  come  in  contact  even  with 
servants  who  have  attended  to  her  before.  '  In  arranging  for  the  isolation  it 
is  necessary  to  tell  the  patient  that  during  her  stay  she  will  not  be  permitted 
to  have  any  communication  whatever,  either  verbal  or  written,  with  her  family 
or  friends,  except  by  special  permission.  It  should  be  said  to  her,  however, 
that  in  case  anything  happens  at  home  which  she  really  should  know  about,  she 
will  be  told ;  hearing  nothing  is  to  mean  to  her  that  everything  is  going  well, 
and  that  there  is  no  reason  for  her  to  worry  about  home  conditions.  When 
the  importance  of  isolation  is  fully  recognized  by  the  physician  and  all  these 
details  are  explained  and  impressed  upon  the  patient,  she  and  her  friends  will 
usually  consent  to  it,  and  a  g-reat  step  forward  has  been  taken  toward  getting 
the  patient  well.  Here  again  individualization  is  necessary,  and  the  physician 
will  after  a  while  acquire  the  experience  which  will  permit  him  to  decide  which 
patient  ought  to  be  isolated  and  which  should  not  be. 

During  the  period  of  complete  rest  and  isolation,  it  is  important,  in  order, 
in  the  first  place,  that  a  strict  regime  may  be  closely  followed,  and  in  the 
second  place  that  the  patient  may  not  be  too  lonesome,  that  she  shall  have 


DIET. 


579 


the  care  of  a  special  nnrsc  who  devotes  herself  entirely  to  her.  The  expense 
of  this  is,  of  course,  prohibitive  in  many  cases,  and  then  one  has  to  make 
compromises  corresponding  to  the  particular  conditions.  Many  cases  do  very 
well  with  the  ordinary  ward  nurses  in  hospitals  and  sanitaria. 

The  diet  of  the  patient  should  be,  of  course,  carefully  looked  after;  a 
very  large  proportion  of  nervous  people  complain  of  disturbances  of 
digestion,  and  a  great  many  prejudices  have  to  be  overcome  at  the  begin- 
ning of  the  treatment.  In  the  majority  of  instances  this  is  best  accomplished 
by  taking  a  firm  stand  with  regard  to  the  administration  of  milk  in  small 
quantities  every  two  hours  during  the  first  few  days  of  the  treatment.  Many 
patients  will  assert  that  it  is  absolutely  impossible  for  them  to  take  milk,  and 
the  physician  in  these  cases  usually  does  well  to  make  a  firm  statement  to  the 
patient  that  in  the  early  stage  of  the  treatment  she  will  receive  nothing  but 
milk.  She  should  be  assured  at  the  same  time  that  given  in  the  way  in  which 
it  will  be  ordered  for  her,  she  will  suffer  little  or  no  inconvenience  from  it 
and  be  able  to  digest  it  satisfactorily.  It  is  well  to  tell  her  that  in  case  she 
seems  to  suffer  from  the  first  feeding  or  two,  she  is  to  pay  no  attention  to 
the  symptoms,  but  to  take  the  ration  of  milk  when  it  comes  with  the  same 
conscientiousness  as  she  would  a  dose  of  medicine.  Even  when  the  patient 
vomits  the  first  feeding  or  so,  I  have  always  found  that  in  functional  cases, 
by  persisting  with  a  small  quantity  every  two  hours,  all  difficulty  is  soon  over- 
come. As  to  the  exact  times  of  giving  the  milk,  I  have  found  the  routine 
administration  recommended  by  Dubois  in  his  book  entitled  "  The  Psychical 
Treatment  of  ISTervous  Disorders,"  to  yield  very  satisfactory  results.  In  the 
wards  of  the  Johns  Hopkins  Hospital  the  food-administration  at  the  begin- 
ning of  treatment  is  as  follows : 


First  day. . 
Second  day 
Third  day . 
Fourth  day 
Fifth  day  . . 
Sixth  day.  . 


Hours  of  Day. 


7  a.m.     9  a.m.    11a.m.     1p.m.      3  p.m.     5  p.m.     7  p.m.     9  p.m 


3 

^ 

6 

9 
12 
12 


3 

^ 

6 
6 
6 
6 


3 

^ 

6 
9 


3 

6^ 


3 

^ 

6 
9 
9 
9 


3 

6 
6 
6 
6 


In  twenty-four 
Hours. 


'24  ounces. 
36  ounces. 
48  ounces. 
57  ounces. 
60  ounces. 
60  ounces. 


On  the  sixth  day  add  bread,  butter,  sweets  or  honey  at  the  first  meal, 
with  the  twelve  ounces  of  milk. 

On  the  seventh  day  the  regimen  changes  abruptly,  and  without  tran- 
sition the  patient  will  take: 

Breakfast. — Twelve  ounces  of  milk,  bread,  butter,  honey,  or  preserves. 

At  ten  o'clock  in  the  morning,  eight  ounces  of  milk. 

Lunch  (or  dinner). — A  full  meal  without  permitting  any  choice.  This 
should  be  varied  and  copious,  but  without  wine. 


580       FUXCTIOXAL    XEKVOUS    DTSOEDEES    MET    WITH    BY    THE    GTIS'ECOLOGIST. 

At  four  o'clock  take  eight  ounces  of  milk. 

Dinner  (or  supper). — Should  be  equally  copious. 

At  nine  o'clock  eight  ounces  of  milk  should  be  taken. 

As  soon  as  solid  food  is  given  the  patient  is  advised  to  masticate  thoroughly, 
adopting  this  feature  of  the  so-called  Fletcher  system : 

"  When  eating  chew  very  thoroughly  everything  that  is  taken  into  the 
mouth  (except  water,  which  has  no  taste)  until  it  is  not  only  liquefied  and 
made  neutral  or  alkaline  by  saliva,  but  until  the  reduced  substance  all  settles 
back  in  the  folds  at  the  back  of  the  mouth  and  excites  the  swallowing  impulse 
into  a  strong  inclination  to  swallow ;  then  swallow  what  has  collected  and  has 
excited  the  impulse,  and  continue  to  chew  at  the  remainder,  liquid  though  it 
be,  until  the  last  morsel  disappears  in  response  to  the  swallowing  impulse, 
l^ever  forcibly  swallow  anything  that  the  instincts  connected  with  the  mouth 
show  any  disposition  to  reject.  It  is  safer  to  get  rid  of  it  beforehand  than  to 
risk  putting  it  into  the  stomach." 

j!*^o  one  measure  has  been  more  successful  in  my  hands  than  the  adoption 
of  this  dietetic  regime,  and  nurses  and  house  ofiicers  who  have  followed  the 
cases  in  the  medical  wards  are  one  and  all  enthusiastic  about  it. 

While  one  need  not  fear  the  administration  of  large  quantities  of  protein 
to  patients  who  are  nervously  below  par,  it  is  perhaps  well  to  give  this  protein 
largely  in  the  form  of  milk  and  eggs,  rather  than  in  the  form  of  meat ;  some 
meat  should  be  given,  but  certainly  not  more  than  one  or  two  portions  per  day. 
Whether  or  not  it  is  the  proteins  of  the  meat  themselves  or  the  extractives  as- 
sociated with  the  proteins  which  are  harmful  to  some  people,  we  do  not  yet 
know.  Most  nervous  patients  appear  to  do  better  when  the  meat  is  not  pushed 
too  much. 

Where  constipation  exists,  the  diet  should  contain  liberal  quantities  of 
stewed  fruits  and  vegetables  (especially  carrots  and  spinach),  and  the  patient 
should  be  advised  to  eat  half  a  pound  of  Graham  bread  per  day.  This  dietary, 
together  with  a  teaspoonful  of  lime  juice  in  a  glass  of  Avater  at  6.30  a.m.,  will 
often  overcome  the  difficulty  of  constipation.  Whether  she  has  the  inclination 
thereto  or  not,  each  patient  should  try  to  have  a  movement  exactly  one  hour 
after  the  beginning  of  her  breakfast  each  morning;  a  regailar  habit  is  in  this 
way  soon  formed.  Until  the  habit  is  established,  the  patient  is  permitted  an 
enema  each  third  day,  in  case  no  natural  movement  occurs.  In  a  few  instances 
one  is  obliged  to  give  cascara  or  some  other  mild  laxative  for  a  time,  but  the 
physician  who  is  conscientious  in  the  treatment  of  constipation  without  drugs 
will  succeed  more  often  than  he  who  resorts  to  drugs  in  every  case. 

When  the  patient  is  resting  in  bed,  it  is  well  to  keep  her  flat  on  her  back 
with  only  one  pillow,  for  several  weeks.  It  is  customary  to  give  a  cold  sponge 
at  55°  to  60°  r.,  followed  by  an  alcohol  rub  each  morning;  some  hydrothera- 
peutic  measure  in  the  evening  is  often  of  advantage.  Where  there  is  insomnia 
especially,  the  cold  pack  will  frequently  give  the  patient  a  good  night's  rest. 
It  is  rarely  necessary  to  use   hypnotics,    and  I  am  convinced  that  one  of  the 


CONVALESCENCE.  581 

commonest  mistakes  made  in  the  treatment  of  nervous  patients  is  the  too  fre- 
quent resort  to  trional,  sulphonal,  veronal,  and  other  sleep-inducing 
drugs ;  a  single  dose  or  two  at  the  beginning  of  the  treatment  may  perhaps  be 
permitted,  but  it  is  interesting  to  find  how  often  insomnia  can  be  gotten  rid  of 
without  the  use  of  any  drug  whatever.  In  my  experience,  the  majority  of  cases 
of  insomnia  yield  without  any  use  of  pharmacotherapy.  A  cold  pack  at  night, 
while  useful  in  many  cases  of  insomnia  and  especially  in  phlegmatic  or  apathetic 
patients,  may  be  actually  harmful  in  a  very  irritable  or  hyperesthetic  woman. 
In  its  place  a  warm  pack  or  a  prolonged  warm  bath  may  yield  better  results. 

During  the  period  of  complete  rest,  the  patient  does  not  sit  up  at  all  except 
on  going  to  stool,  or  when  propped  up  in  bed  with  pillows,  for  her  meals. 
Where  it  is  possible  to  run  the  patient's  bed  out-of-doors  in  the  daytime,  it 
is  very  desirable  to  do  so;  even  in  the  coldest  winter  weather  these  nervous 
patients  do  well  out-of-doors.  They  must,  of  course,  be  kept  warm ;  if  necessary 
with  the  use  of  Jaeger  underwear,  blankets  underneath  as  well  as  above  the 
patient,  hot-water  bottles,  and  a  woolen  cap  for  the  head.  Patients  may  sleep 
out-of-doors  at  night,  or  if  they  sleep  in  bedrooms,  they  should  have  all  the 
windows  of  their  room  widely  open. 

At  the  end  of  the  period  of  rest,  usually  at  the  end  of  about  five  weeks,  the 
patient  begins  to  sit  up ;  during  the  first  day  she  is  given  a  back  rest  for  one 
hour,  and  this  is  increased  to  tw^o  hours  on  the  next  day.  On  the  third  and 
fourth  day  she  is  permitted  to  sit  in  a  wheel-chair  for  an  hour,  and  the  time 
is  gradually  increased  during  the  next  few  days.  On  the  eighth  day  a  walk 
of  ten  minutes  is  allowed,  and  if  all  goes  well,  the  walk  is  increased  until  at 
the  end  of  a  fortnight,  or  even  less,  the  patient  may  walk  five  miles  a  day  with- 
out special  fatigue.  If  much  weight  has  been  put  on,  care  must  be  taken  that 
the  arches  of  the  feet  do  not  yield  to  strain  at  this  time,  and  if  pain  is  com- 
plained of  on  walking,  suitable  orthopedic  shoes,  or  even  temporary  supporting 
plates  for  the  feet,  may  be  required.  When  the  patient  begins  to  be  up  and 
about  she  is  allowed  a  quick  morning  plunge  in  water  at  the  tap  temperature, 
and  this  replaces  the  cold  sponge  of  the  resting  period.  Setting-up  exercises 
and  calisthenics  are  often  advantageous  during  the  after-cure,  and  mild  forms 
of  occupation,  sewing,  knitting,  crochet  work,  and  the  like,  are  helpful. 

Early  in  the  cure,  even  when  the  patient  is  at  complete  physical  rest,  the 
nurse  is  instructed  to  read  aloud  for  periods  of  increasing  length  during  the 
day,  and  later  on,  the  patient  may  be  permitted  to  read  herself  under  super- 
vision as  to  time  and  subject,  being  thus  gradually  led  back  to  normal  life  and 
intercourse. 

Special  dietetic  measures  are  necessary  where  there  is  a  tendency  to 
obesity,  to  diabetes,  or  to  gout,  the  details  of  which  cannot  be  consid- 
ered here.  In  patients  suffering  from  hyperthyroidism,  the  protein  portion  of 
the  diet  should  consist  almost  wholly  of  milk,  inasmuch  as  meat  seems  to  stimu- 
late the  activity  of  the  thyroid  gland. 

Massage   is  an  important  aid  in  the  administration  of  the  rest  cure,  espe- 


582        FUNCTIONAL    NERVOTJS    DISOKDEES    MET    WITH    BY    THE    GYNECOLOGIST. 

ciallj  in  that  it  makes  tlie  patient  more  comfortable  in  bed.  There  is  a  mistaken 
idea  abroad  that  it  takes  the  place  of  exercise  by  influencing  metabolism  in  a 
similar  way.  Careful  metabolic  studies  prove  that  there  is  no  metabolic  effect 
from  massage  comparable  with  that  which  is  exerted  by  physical  exercise.  It 
seems  probable,  therefore,  that  massage  in  nervous  patients  exerts  its  good  effect 
through  stimulation  of  the  sensory  nerves  of  the  skin  and  muscles,  through 
facilitation  of  the  lymph  flow,  and,  in  part  at  least,  through  its  psychic  effect. 

More  important,  however,  than  the  rest,  the  diet,  and  the  massage  in  the 
treatment  of  the  psychoneuroses  is  the  use  of  the  patient's  mind  in 
bringing  about  the  cure.  Psychotherapy  and  re-education  are  the  sheet 
anchors  of  the  therapeutist  in  the  functional  neuroses. 

The  exact  mode  of  application  of  the  psychic  measures  in  the  treatment  of 
nervous  disease  will  vary  with  each  practitioner,  and  everyone  does  best  to 
develop  the  methods  most  suitable  to  his  own  personality  and  his  own  needs. 
Certain  general  directions,  however,  may  be  helpful,  and  certainly  during  the 
last  fifty  years  great  progress  has  been  made  in  the  application  of  psychic 
methods  in  re-educating  nervous  patients  back  to  health.  At  the  outset  of  the 
treatment  a  full  explanation  of  the  condition  of  the  patient  to  herself  is  a  great 
help.  It  is  unwise  to  deceive  her.  If  an  organic  lesion  exists,  it  should 
not  be  denied,  although  it  may  be  necessary  to  refrain  from  laying  emphasis 
upon  it.  Any  direct  question  that  the  patient  may  ask  should  be  frankly  an- 
swered, and  she  should  be  told,  as  far  as  the  physician  is  able  to  tell  her,  the 
meaning  of  any  lesion  which  exists  and  the  relation  of  the  symptoms  to  it.  If 
no  organic  lesion  can  be  found  on  the  application  of  careful  tests,  it  is  a  great 
comfort  to  the  patient  to  be  told  unhesitatingly  by  the  physician  the  negative 
results  of  the  study.  Her  mind  is  relieved,  and  when  she  is  assured  by  the 
doctor  that  the  sj-mptoms  are  in  his  opinion  "  nervous  "  in  origin,  and  curable, 
her  hope  is  excited  and  she  makes  a  start  toward  getting  well. 

Much  encouragement  is  necessary  to  the  depressed  patient,  especially  where 
a  fear  of  insanity  or  of  incurable  disease  exists,  and  the  physician  who  under- 
takes properly  to  care  for  these  patients  must  be  willing  to  spend  a  good  deal 
of  time  with  them.  A  visit  of  half  a  minute  or  a  minute  is  totally  insufiicient ; 
they  often  require  a  long  explanation  and  a  full  statement,  especially  at  the 
outset.  Too  much  time,  however,  should  not  be  spent  with  the  patient,  for  then 
the  physician's  assurances  will  lose  in  force.  Brief,  clear,  and  emphatic 
pronouncements  are  most  helpful;  argumentation  with  a  nervous  patient 
should  never  be  indulged  in,  for,  in  my  experience,  it  only  does  harm  to  argue 
with  irritable  nerves. 

The  method  of  avowal,  that  is  the  open  declaration  by  the  patient  to  the 
physician  of  any  painful  or  secret  experience  which  she  may  believe  to  be  as- 
sociated with  the  origin  of  her  symptoms,  should  be  encouraged.  The  delicacy 
of  such  conversations  should,  however,  always  be  borne  in  mind,  and  the  physi- 
cian must  win  the  confidence  of  liis  patient  before  lie  can  expect  full  frankness 
i-tegarding  these  experiences.     Any  unnecessary  inquisitiveness  into  the  patient's 


PSYCHOTHERAPY.  583 

past  experiences  should  always  be  avoided,  and  when  an  avowal  is  necessary 
and  important,  the  physician  should  see  to  it  that  it  is  made  without  injury 
to  the  self-respect  of  the  patient.  The  physician  should  not  shrink  from  the 
trouble  of  listening  to  the  unburdening  of  soul;  a  knowledge  of  the  mental 
content  of  the  patient  will  often  give  him  clues  for  the  exertion  of  salutary 
psychic  influences,  and  the  "  confession  "  is  nearly  always  followed  by  relief  to 
the  patient. 

In  this  connection  the  so-called  "  psycho-analysis,"  described  by  Freud,  of 
Vienna,  is  very  interesting.  By  this  method,  an  attempt  is  made  to  discover 
by  particular  association  tests  the  existence  of  complexes  of  ideas  to  which 
strong  feelings  are  attached.  Jung,  of  Zurich,  has  of  late  been  working  out 
a  method  which  he  asserts  is  practical  for  clinical  analysis,  and  Jung's  method, 
it  is  said,  yields  results  much  more  quickly  than  the  slower  process  used  by 
Freud.  By  the  use  of  suitable  stimulus-words  and  watching  the  reactions,  it 
seems  possible  to  tell  when  a  definite,  painful,  psychic  complex,  unbearable  in 
the  patient's  consciousness  and  accordingly  suppressed,  has  been  touched.  By 
laying  this  complex  bare  and  disintegrating  it,  it  is  said  to  be  possible  to  help 
severe  forms  of  psychoneuroscs  which  have  been  entirely  irresponsive  to  other 
therapeutic  means ;  especially  in  the  severer  forms  of  hysteria,  successes,  it  is 
said,  have  been  scored  by  this  method. 

The  two  most  important  measures  in  psychotherapy  are,  however,  those 
known  as    persuasion    and   suggestion. 

In  the  use  of  persuasion  the  physician  makes  an  appeal  to  the  higher  psychic 
functions;  the  mind  is  won  over  by  the  presentation  of  suitable  reasons,  and 
not  by  the  exertion  of  authority,  force,  or  fear.  In  suggestion,  on  the  contrary, 
an  idea  is  introduced  into  the  brain  of  the  individual  without  his  control ;  the 
higher  functions  are  not  utilized,  or  if  affected,  they  are  inhibited ;  the  influ- 
ence is  exerted  through  the  subconscious  mind. 

Even  when  an  effort  is  made  to  restrict  psychotherapeutic  efforts  to  persua- 
sion, just  now  the  measure  more  popular  among  medical  men,  it  is  difficult  to 
say  how  much  of  the  effect  is  really  due  to  persuasion,  and  how  much  of  it  to 
suggestion;  at  any  rate,  the  physician  usually  feels  more  comfortable  himself 
if  he  endeavors  to  produce  his  psychotherapeutic  effects  through  the  use  of  the 
patient's  reason,  than  by  resorting  to  the  more  occult  influence  through  the 
subrational. 

The  establishment  of  medical  obedience  from  the  very  be- 
ginning of  the  treatment  is  essential.  The  cooperation  of  the  patient 
must  be  gained,  and  she  must  give  an  imequivocal  consent  to  do  exactly  what 
she  is  told  to  do,  at  least  during  the  first  period  when  she  is  under  the  physi- 
cian's care.  She  sliould  be  told  that  she  will  not  be  asked  to  do  anything  un- 
reasonable, or  to  follow  any  instructions  prejudicial  to  her  welfare,  but  that 
slie  must  obey,  even  wlien  the  reason  of  some  of  the  orders  may  not  be  clear 
to  her,  or  seem  to  her  trivial  and  arbitrary.  It  is  wise  to  leave  nothing  to  the 
decision  of  the  patient  at  first,  and  it  is  especially  important  that  neither  the 


584       FUNCTIONAL    NERVOUS    DISORDERS    MET    WITH    BY    THE    GYNECOLOGIST. 

doctor  nor  the  nurse  yield  to  whimsical  requests,  or  alter  a  routine  inaugurated, 
because  the  patient  offers  objection  to  it.  Exhortation  and  all  forms  of  moral 
treatment  are  better  avoided  at  the  beginning,  especially  in  the  severer  cases. 
Later  on  the  patient  will,  in  all  probability,  wake  up  to  an  understanding  of 
her  condition  herself,  or  she  may  be  gradually  instructed  regarding  it.  After 
the  physical  side  of  the  treatment  has  been  fully  cared  for,  it  will  become  neces- 
sary by  steady  training  to  improve  the  attention  of  the  patient,  and  to  educate 
her  emotions  and  her  will.  Gradually,  as  a  result  of  this  training,  she  may 
learn  completely  to  control  herself,  and  the  medical  absolutism  may  be  replaced 
by  self-direction.  As  Dubois  points  out,  it  is  well  to  hold  before  her  the  ideal 
of  "  mistress  of  herself,"  as  something  at  which  she  must  constantly  aim. 

The  physician  should  not  underestimate  the  importance  of  a  proper  kind 
of  nurse  to  aid  him  in  the  treatment  of  his  nervous  patients.  ISTot  every 
woman  graduated  from  a  training  school  is  suited  to  this  kind  of  work.  It  is 
necessary  that  the  special  nurse  have  a  strong  character,  and  good  control  of 
her  own  emotions ;  moreover,  it  is  desirable  that  she  have  an  education  equal  to 
or  better  than  that  of  the  patient  whom  she  cares  for.  If  she  also  possess  the 
social  qualities  which  will  endear  her  to  her  patient,  it  is  a  distinct  advantage. 
Above  all  she  must  know  how  to  make  herself  respected  and  esteemed,  and  she 
should  be  given  adequate  authority,  in  order  that  her  directions  shall  be  fol- 
lowed, although  it  is  an  essential  that  in  all  her  relations  to  the  patient  she 
must  be  good-natured  and  kind.  The  physician,  on  his  visits  to  the  patient, 
must  show  by  his  behavior  to  the  nurse  that  he  regards  her  as  his  representative 
in  his  absence,  that  he  has  confidence  in  her,  and  that  he  expects  the  patient 
to  consent  to  everything  that  is  done  for  her  without  objection.  It  is  just  as 
well,  however,  for  the  nurse  to  let  the  patient  feel  that  everything  that  is  done 
for  her  is  the  result  of  specific  instructions  given  by  the  physician,  for  patients 
will  resent  discipline  which  they  have  reason  to  believe  has  originated  in  the 
nurse's  rather  than  in  the  doctor's  mind.  During  convalescence  the  physician 
must  avail  himself  of  various  methods  of  psychic  stimulation  and  re- 
education, and  here  his  knovdedge  of  the  world  and  of  the  men  and  women 
in  it,  their  hopes,  their  desires,  and  their  failings,  will  be  most  helpful  to  him. 
He  must  consider  how  to  keep  the  attention  of  his  patient  focussed  upon  her 
cure,  and  how  to  prevent  her  from  giving  herself  unhealthy  suggestions.  In 
other  words  he  must  teach  her  so  to  train  her  attention  that  the  action  of  the 
mind  becomes  healthy,  and  that  it  cease  to  dwell  upon  the  abnormal.  He  must 
excite  in  his  patient  the  desire  to  get  well,  and  must  convince  her  as  the  treat- 
ment progTesses  that  she  is  in  reality  getting  well.  He  must  teach  her  the 
importance  of  overcoming  little  difiiculties,  assuring  her  that  as  she  does  one 
thing  after  another  to  which  she  may  be  disinclined,  she  will  acquire  an  ever- 
increasing  power  of  self-control,  and  that  sooner  or  later  her  self-mastery  will 
be  regained. 

On  the  emotional  side,  a  prolonged  training  is  often  necessary  in  order 
to  get  rid  of  abnormal  fears,  anxiety,  and  apprehension.     The  patient  should 


PSYCHOTHEEAPT.  585 

be  taught  to  cultivate  the  useful  and  invigorating  emotions;  she  should  be 
taught  the  dangers  of  excessive  emotion  of  any  kind,  and  the  great  harm  of 
indulging  in  such  passions  as  anger,  hate,  and  fear.  The  positive 
rather  than  the  negative  side  should  be  followed.  Faith,  hope,  and  love 
should  be  encouraged,  and  then  worry,  fear,  and  despair  will  disappear 
of  themselves.  Finally,  work,  physical  and  mental,  must  be  undertaken,  for 
in  a  projDerly  directed  occupation-therapy  lies  the  greatest  hope  for  mak- 
ing the  cure  permanent.  These  nervous  women  have  to  be  educated  gradually 
how  to  take  up  their  work,  and  the  physician's  ingenuity  will  be  greatly  taxed 
in  order  to  decide  as  to  the  particular  physical  and  mental  occupations  suited 
to  the  individual  cases  coming  under  his  care ;  one  patient  will  be  benefited 
by  gardening,  another  by  some  active  mental  pursuit.  In  all  cases  the  program 
of  the  day  should  be  carefully  arranged,  and  the  patient  should  be  encouraged 
to  follow  it  closely.  The  work  should  be  chosen  in  accordance  with  the  ability 
and  previous  training  and  occupation  of  the  patient.  It  should  be  interesting 
to  her  and  should  be  such  as  to  be  capable  of  giving  expression  to  her  better  self. 
This  is  scarcely  the  place  to  deal  with  the  use  of  suggestion,  and  es- 
pecially of  hypnotic  suggestion.  That  this  method  of  therapy  is  ad- 
vantageous in  some  cases  there  can  be  no  doubt,  but  experience  has  taught  that 
the  application  of  hypnotism  is  much  more  limited  than  those  who  hailed  it  so 
enthusiastically  at  first  were  inclined  to  believe.  It  is  possible,  however,  that 
fear  of  the  appearance  of  quackery  and  charlatanism  has  prevented  physicians 
from  making  use  of  this  measure  even  to  the  extent  to  which  it  may  very 
properly  be  applied. 


CHAPTEE    XXIV. 

APPENDICITIS  AND  DISEASES  OF  THE   PELVIC  ORGANS. 

Conditions  under  which  appendicitis  is  associated  with  disease  of  the  pelvic  organs,  p.  586.  Ap- 
pendicitis and  coexisting  pelvic  disease:  Inflammatory  disease,  p.  587;  tuberculosis,  p.  588 
tumors,  p.  588.  Independent  affections  of  the  appendix  and  the  pelvic  organs,  p.  589 
Differential  diagnosis  between  appendicitis  and  pelvic  disease:  Inflammatory  disease,  p.  589 
ovarian  cyst,  p.  590;  ruptured  tubal  pregnancy,  p.  591.  Appendicitis  and  dysmenorrhea, 
p.  592.     Appendicitis  in  the  child,  p.  595. 

CONDITIONS   OF  ASSOCIATION    BETWEEN  APPENDICITIS  AND    PELVIC 

DISEASES. 

The  earliest  allusion  to  a  relation  between  inflammation  of  the  appendix 
and  diseases  of  the  reproductive  organs  was  made,  I  believe,  by  H.  C.  Coe 
(Neio  York  Polyclinic,  1894,  vol.  4,  p.  73),  and  almost  simultaneously  by  J. 
T.  Binkley  (Amer.  Jour.  Obst,  1894,  vol.  29,  p.  474).  Both  of  these  ob- 
servers call  attention  to  the  fact  that  appendicitis  may  be  associated  with  disease 
of  the  uterine  adnexa,  and  that  the  primary  infection  may  be  seated  either  in 
the  appendix  or  in  the  tubes  and  ovaries.  Contributions  to  the  subject  have 
appeared  repeatedly  since  then,  and  it  is  now  a  well-recognized  fact  that  disease 
of  the  pelvic  organs  in  women  may  be  associated  with  disease  of  the  appendix 
in  any  one  of  the  three  following  ways : 

First,  the  disease  of  the  appendix  is  primary  and  that  of  the 
pelvic  organs  secondary.  Second,  the  disease  of  the  pelvic  or- 
gans is  primary  and  that  of  the  appendix  secondary.  Third, 
the  disease  of  the  pelvic  organs  and  the  disease  of  the  appendix 
coexist,    independently   of   each   other. 

In  my  clinic  at  the  Johns  Hopkins  Hospital  I  had  occasion,  during  the  ten 
years  immediately  preceding  the  year  1904,  to  remove  the  appendix  in  two 
hundred  and  forty  cases,  the  majority  of  which  were  combined  gynecological 
and  appendical  affections.  Of  these  two  hundred  and  forty  cases,  there  were 
ninety  of  acute  appendicitis  uncomplicated  with  any  gynecological  affection ;  in 
sixteen  others  the  appendix  was  removed  purely  as  a  prophylactic  measure ; 
while  in  the  remaining  one  hundred  and  thirty -four  cases  a  gynecological 
affection  of  some  kind  was  associated  with  disease  of  the  appendix.  These 
statistics  agree  very  fairly  with  those  of  Hermes  {DeuUcli.  Zeitsclir.  f.  CJiir., 
1903,  vol.  68,  p.  191)  and  of  Peterson  (Trans.  Amsr.  Gyn.  Soc,  1904,  vol.  29, 
p.  350).  Hermes  performed  seventy-fivo  la]3arotomies  for  the  relief  of  pelvic 
disease  and  found  that  in  forty  cases,  or  a  little  over  fifty-three  per  cent,  the 
586 


APPENDICITIS    AND    ASSOCIATED    PELVIC    DISEASE.  587 

appendix  was  affected;  while  Peterson,  in  two  hundred  operations  of  the  same 
kind,  found  that  the  appendix  was  diseased  in  nearly  fifty  per  cent. 

APPENDICITIS    AND    ASSOCIATED    PELVIC    DISEASE. 

In  some  cases  where  it  is  definitely  known  that  a  gynecological  affection 
exists,  it  is  a  matter  of  importance  to  decide  whether  or  not  there  is  a  com- 
plicating appendicitis.  The  fact  that  the  appendix  is  frequently  involved  in 
pelvic  affections  is  now  too  well  known  for  such  accidents  to  occur  as  that  re- 
ported some  years  ago  by  Tait  and  Wiggin,  in  which,  during  the  course  of  an 
operation  upon  the  pelvic  organs,  the  appendix  (being  involved  in  dense  ad- 
hesions) was  removed  without  the  knowledge  of  the  operator,  and  the  fact  dis- 
covered only  on  the  autopsy  table.  It  must  always  be  remembered  that  when 
independent  affections,  either  acute  or  chronic,  coexist,  one  may  be  masked  by 
the  predominating  symptoms  of  the  other.  This  fact  is  of  special  importance 
in  the  case  of  an  acute  pelvic  inflammation.  Appendicitis  should  be  suspected 
when  there  is  extreme  severity  of  both  abdominal  and  constitutional  symptoms, 
with  paroxysmal  pain  localized  at  or  near  McBurney's  point. 

Pelvic  Inflammatory  Disease. — Pelvic  inflammation  is  by  far  the  most 
frequent  disease  of  the  pelvic  organs  complicating  appendicitis.  Out  of  the 
hundred  and  thirty-four  cases  in  my  clinic  in  which  appendicitis  was  found  to 
be  associated  with  pelvic  disease  of  one  kind  or  another,  there  were  sixty-four 
in  which  the  pelvic  affection  was  inflammatory.  In  the  majority  of  cases 
in  which  inflammation  of  the  pelvic  organs  and  disease  of  the 
appendix  are  associated,  the  primary  infection  is  in  the  pelvis. 
The  associated  diseased  conditions  are  not  always  on  the  right  side,  for  in 
the  case  of  an  unusually  long  appendix  and  an  abnormally  movable  cecum, 
it  is  quite  possible  for  the  appendix  to  become  attached  to  the  left  tube  or 
ovary.  In  forty-four  cases,  cited  by  Peterson,  the  disease  was  confined  to  the 
right  adnexa  in  eight  instances,  to  the  left  adnexa  in  six,  while  in  thirty  cases 
both  sides  were  affected. 

Even  when  the  appendix  does  not  occupy  the  pelvic  position  it  is  possible 
for  it  to  become  infected  under  certain  conditions,  as  in  puerperal  infec- 
tions or  in  gonorrheal  salpingitis,  if  the  enlarged  tube  happens  to  be 
situated  a  little  higher  up  than  usual.  Generally  the  appendix  is  attached  to 
the  tubo-ovarian  mass  by  more  or  less  firm  adhesions,  the  appendix  itself  show- 
ing practically  no  gross  changes ;  but  careful  examination  of  such  appendices 
reveals  that  comparatively  few  are  perfectly  healthy,  a  mild  catarrhal  inflam- 
mation being  the  affection  most  often  found.  More  severe  lesions  are  not  un- 
common, an  unsuspected  diffuse  inflammation  being  found  in  certain 
cases  at  operation;  moreover,  there  may  be  various  residual  conditions, 
namely,    strictures,    obliteration,    or   cystic    distention. 

The  causal  relation  of  the  pelvic  disease  to  the  inflammation 
of    the    appendix    may    be    direct    or    indirect.      In  the  first  case,  the 


5gg  APPEXDICITIS    AXD    DISEASES    OF    THE    PELVIC    OEGAXS. 

appendix  is  involved  in  the  pelvic  exudate  from  the  beginning;  the  adhesions 
thus  formed  become  organized,  and  blood  and  lymph  vessels  are  established 
between  the  appendix  and  the  tube,  through  which  the  infection  is  readily- 
transmitted.  It  seems  probable,  however,  that  the  pelvic  disease  usually  limits 
the  movements  of  the  appendix  by  fixing  it  in  adhesions,  and  by  producing 
stasis,  acts  as  a  predisposing  factor  in  the  development  of  appendicitis.  The 
history  of  the  onset  and  progress  of  the  illness  is  the  most  important  point  in 
determining  its  original  focus.  It  is  frequently  possible  to  obtain  a  clear  his- 
tory of  puerperal  or  gonorrheal  infection;  but  in  these  cases,  clinical 
evidence  of  the  appendical  complications,  as  a  rule,  is  conspicuously  absent. 

Tuberculosis  of  the  Pelvic  Organs. — This  condition  not  infrequently  involves 
the  appendix  in  the  peritoneal  adhesions  which  usually  accompany  it,  and  in  a 
numlier  of  cases  the  walls  of  the  appendix  are  invaded  by  the  tul^ercular  process, 
even  where  there  is  no  evidence  of  other  extension  of  the  disease.  Out  of  seven 
cases  which  I  examined,  where  the  appendix  was  adherent  to  the  tubercular 
tulje.  it  was  slightly  infiltrated  with  tubercles  in  four. 

Tumors  of  the  Tterus  and  Ovaries.- — Adhesions  between  the  appendix  and 
cysts  of  the  right  ovary  are  frequently  observed,  and  occasionally  the  appendix 
is  attached  to  a  left  ovarian  cyst.  Out  of  about  three  hundred  operations  for 
cystoma  in  the  Jolms  Hopkins  Hospital,  the  appendix  was  found  adherent 
to  tumors  of  the  right  side  in  sixteen  cases,  and  to  those  of  the  left  in  three. 
In  some  instances  the  appendix  is  merely  secondarily  involved  in  the  general 
adhesions  which  so  frequently  surround  pelvic  tumors,  and  are  the  residue  of 
an  old  widespread  peritoneal  reaction.  Dermoids  and  cysts  with  torsion 
of  the  pedicle  are  particularly  apt  to  give  rise  to  general  adhesions,  and  it 
is  in  such  cases  that  the  appendix  is  most  often  involved.  In  our  series  of 
cases,  the  cyst  had  become  twisted  upon  its  pedicle  in  one-fourth,  and  in  these 
the  appendical  adhesions  were  unusually  dense  and  extensive.  In  some  in- 
stances the  appendix  is  adherent  to  the  otherwise  smooth  surface  of  the  cyst,  or 
to  the  broad  ligament.  In  some  cases  the  tip  only  is  adherent ;  in  others  the 
entire  appendix,  including  its  mesentery,  is  plastered  to  the  surface  of  the 
tumor.  The  organ  itself  may  be  practically  normal,  but  in  the  majority  of 
instances  its  walls  are  thickened  and  rigid,  while  kinks,  strictures,  and  other 
results  of  an  inflammatory  process  are  commonly  present. 

Parovarian  cysts  also  are  frequently  complicated  by  appendical  ad- 
hesions or  by  acute  or  chronic  appendicitis.  In  malignant  ovarian  growths  the 
appendix  may  become  invaded  secondarily  by  the  new  growth.  Uterine 
myomata  are  less  frequently  complicated  by  disease  of  the  appendix  than 
ovarian  cysts,  and  as  in  ovarian  tumors  the  appendix  usually  presents 
evidence  of  chronic  inflammatory  changes.  Extra-uterine  pregnancy  is 
complicated  with  a]ipendicitis  in  a  considerable  number  of  instances.  Person- 
ally, I  recall  seven  cases,  forming  al)Out  ten  per  cent  of  the  cases  of  extra-uterine 
pregnancy  in  my  clinic,  in  which  the  appendix  was  adlierent  to  the  sac,  or  was 
acutelv  inflamed. 


APPENDICITIS    AND    COEXISTING    PELVIC    DISEASE.  589 

INDEPENDENT    AFFECTIONS    OF    THE    APPENDIX   AND    THE 

PELVIC    ORGANS. 

The  possibility  of  the  coexistence  of  pelvic  and  appendical  disease  must 
always  be  borne  in  mind,  especially  in  cases  which  are  being  treated  for  pelvic 
disease.  Quite  often,  after  removal  of  ovarian  or  uterine  tumors  not  compli- 
cated by  adhesions,  investigation  of  the  cecal  region  will  reveal  the  presence 
of  independent  appendical  disease.  Thus,  in  a  case  of  myoma  under  my  own 
care,  the  appendix  was  found  completely  filled  and  distended  by  two  large  con- 
cretions; in  another  case  of  myoma,  the  appendix  was  obliterated  and  en- 
veloped in  adhesions.  In  cases  of  extra-uterine  pregnancy  the  existence 
of  an  independent  appendicitis  has  been  frequently  observed.  T.  II.  Chase 
{Halm.  Month.,  1903,  vol.  38,  p.  520)  cites  an  interesting  case  of  a  young 
woman  who  was  brought  into  the  hospital  with  a  history  of  trauma  over  the 
right  lower  quadrant  of  the  abdomen,  produced  by  falling  face  downwards  in 
the  street  upon  a  pile  of  cobble-stones.  On  her  entrance,  three  bruises  were 
visible  over  the  right  iliac  fossa.  After  keeping  her  under  observation  for  a 
few  days  the  abdomen  was  opened,  and  a  chronic  salpingitis  was  found  on  the 
right  side,  with  an  acutely  inflamed  appendix,  but  no  sigTis  of  communication 
between  the  two. 

The  treatment  of  appendicitis  and  coexisting  pelvic  disease,  whether  in- 
dependent of,  or  related  to  each  other,  belongs  in  almost  all  cases  to  the  surgeon, 
and  such  cases  should  be  referred  to  him  as  soon  as  they  are  recognized. 

DIFFERENTIAL   DIAGNOSIS   BETWEEN   APPENDICITIS   AND    PELVIC 

DISEASE. 

The  differential  diagnosis  between  appendicitis  and  disease  of  the  pelvic 
organs  is  of  much  more  importance  to  the  general  practitioner  than  the  diag- 
nosis of  coexisting  disease,  whether  independent  or  not,  because  in  the  early 
stages  of  certain  affections,  early  salpingitis  for  example,  palliative 
treatment  may  be  all  that  is  needed;  whereas,  in  acute  appendicitis, 
immediate   operation   is  imperative. 

Inflammatory  Disease  of  the  ITterine  Adnexa. — The  affection  most  often  con- 
founded with  appendicitis  in  women  is  inflammation  of  the  ovaries  and 
tubes.  Each  condition  presents  characteristic  differences,  however,  and  careful 
attention  to  these  and  to  the  history  of  the  case  in  its  early  stages  ought  to 
prevent  mistakes.  Abdominal  pain,  associated  with  nausea  and  vomit- 
ing, may  appear  as  suddenly  in  one  affection  as  in  the  other,  and  there  may  be 
pain  on  local  pressure  over  the  right  lower  abdomen  in  both,  but  in  pelvic 
disease  the  local  pain  and  tenderness  are  usually  situated  more  deeply  in  the 
pelvis  and  the  right  inguinal  region,  intense  suffering  being  elicited  on  deep  pal- 
pation over  Poupart's  ligament.  Vaginal  examination  may  show  ten- 
derness in  both   cases,   but  if  it  is  on  both  sides,  or  is  confined  to  the  left 


590  APPENDICITIS    AND    DISEASES    OF    THE    PELVIC    ORGANS. 

side,  the  trouble  is  probably  perimetritis  and  not  appendicitis.  There  are,  how- 
ever, cases  in  which  confusion  may  arise  because  the  appendix  occupies  the 
pelvic  position,  and  therefore  the  pain  and  tenderness  are  situated  deep  down  in 
the  pelvis ;  moreover,  if  the  organ  is  of  unusual  length,  it  may  extend  to  the  left 
even  as  far  as  the  ojDposite  side.  In  such  cases  reliance  must  be  placed  on  the 
earlier  symptoms  as  described  in  the  history.  In  the  onset  of  appendicitis  the 
pain  is  apt  to  be  paroxysmal  in  character,  while  in  pelvic  inflammation  it  is 
more  steady  and  less  intense.  Pelvic  inflammation  is  usuall}'  accompanied  in 
the  early  stages  by  a  vaginal  discharge,  sometimes  of  a  yellowish  character,  and 
often  associated  with  burning  on  urination ;  these  symptoms  may  exist  several 
days  before  the  abdominal  pain  appears.  With  appendicitis  there  is  often  a 
history  of  previous  attacks  of  pain  or  digestive  disturbance.  It  is  not  usual  to 
find  a  tumor  in  the  early  stages  of  either  affection,  but  later  on  a  more  or  less 
well-defined  resistance,  situated  posterior  or  lateral  to  the  uterus,  is  generally 
present  in  both,  and  it  may  signify  either  pelvic  inflammation  or  pelvic  ap- 
pendicitis. In  appendicitis,  however,  the  resistance  is  usually  situated  higher 
up  and  extends  from  the  posterior  border  of  the  right  broad  ligament  to  the 
iliac  fossa;  whereas  in  pelvic  inflammatory  disease  the  tumor  is  deep  down 
in  the  pelvis,  and  it  is  often  possible  to  determine  the  enlarged  tube  by  bi- 
manual, vaginal,  and  rectal  palpation.  R.  T.  Morris  considers  that  abdom- 
inal rigidity  is  the  principal  diagTiostic  sign  between  acute  appendicitis  and 
salpingitis.  If  it  is  absent,  appendicitis  may  be  excluded  with  tolerable  cer- 
tainty. When  an  acute  pelvic  inflammation  is  accompanied  by  a  spreading  or 
general  peritonitis  it  cannot  be  distinguished  from  appendicitis,  unless  there  is 
an  unusually  clear  and  reliable  history. 

The  development  of  a  pelvic  infection  in  a  young  girl,  or  an  unmarried 
woman  of  good  character,  should  always  excite  a  suspicion  of  primary  appendi- 
citis, even  when  bimanual  examination  shows  definite  disease  of  the  adnexa  on 
both  sides,  as  in  many  cases  it  will  be  found  on  operation  that  the  tubo-ovarian 
disease  is  due  to  a  secondary  infection  of  the  tube.  As  MacLaren  observes, 
"  a  young  woman's  reputation  may  be  smirched  by  the  discovery  of  pus  tubes, 
where  operation  demonstrates  that  the  tubal  suppuration  was  due  entirely  to 
inflammation  of  the  appendix." 

Ovarian  Cyst. — Confusion  in  the  diagnosis  between  appendicitis  and  ovarian 
cyst  with  torsion  of  the  pedicle  is  very  common.  N^iot  (These  de  Paris,  1901) 
cites  eleven  instances  of  dermoid  cysts  with  twisted  pedicle,  mistaken 
for  appendicitis ;  and  in  two  out  of  five  cases  of  torsion  observed  by  Fowler,  the 
patient  had  been  sent  to  the  hospital  with  a  diagnosis  of  appendicitis.  Acute 
torsion  is  most  apt  to  occur  in  cysts  of  medium  size,  which  have  not  previously 
produced  any  swelling,  the  subjective  symptoms  being  absent  or  very  insig- 
nificant, and  this  makes  the  diagnosis  difficult.  The  sudden  onset  of  severe 
pain,  often  accompanied  by  nausea  and  vomiting,  may  closely  simulate  acute 
appendicitis.  In  the  early  stages  the  character  of  the  pain  is  diffuse  and  con- 
tinuous, while  in  acute  appendicitis,  before  localization  in  the  right  iliac  fossa, 


DIFFERENTIAL    DIAGNOSIS    BETWEEN    APPENDICITIS    AND    PELVIC    DISEASE.     591 

it  is  colicky;  at  a  later  stage,  after  peritonitis  lias  supervened,  the  pain  is  very 
iiiucli  the  same  in  both  conditions.  Sometimes  it  is  possible  to  distinguish  at 
the  outset  a  well-rounded,  elastic  ovarian  tumor,  while  in  appendicitis  a  tumor 
is  rarely  observed  in  the  early  stages,  and,  if  it  is,  it  has  not  the  sharp  outline 
of  the  cyst.  Fluctuation  is  sometimes  suggested  as  a  guide  in  the  diagnosis 
of  some  kinds  of  dermoids  and  multilocular  cysts,  but  it  is  an  indefi- 
nite sign,  and  not  to  be  depended  upon.  Palpation,  which  may  be  serviceable 
in  outlining  the  tumor,  is  unsatisfactory  in  many  cases  on  account  of  the  rigidity 
of  the  abdominal  walls.  In  the  case  of  a  cyst,  the  tumor  is  sometimes  readily 
palpable  after  the  early  acute  reaction  subsides;  whereas,  in  appendicitis  not 
complicated  with  diffuse  peritonitis,  the  abdomen,  with  the  exception  of  the 
region  of  the  appendix,  becomes  soft  and  natural.  When  peritonitis  complicates 
the  situation,  a  differential  diagnosis  is  impossible,  but  in  general  it  may  be 
noted  that  the  peritonitis  accompanying  ovarian  cysts  is  of  a  milder  type,  and 
is  not  associated  with  the  severe  constitutional  symptoms  observed  in  peritonitis 
originating  from  appendicitis ;  moreover,  the  abdominal  tenderness  is  usually 
pronounced.  Examination  by  the  vagina  and  the  rectum  may  afford  valuable 
information  regarding  the  nature  of  the  trouble,  and  it  may  be  possible  in  this 
way  not  only  to  outline  the  cyst,  but  also  to  recognize  the  twisted  pedicle,  which 
is  felt  extending  from  the  side  of  the  uterus  up  to  the  abdominal  mass. 

Several  instances  have  been  reported  of  a  mistake  in  diagnosis  be- 
tween appendicitis  and  ovarian  disease  in  the  child.  In  one  of 
these,  reported  by  Porter  (1892),  the  little  girl,  who  was  eleven  years  old,  had 
shown  no  signs  of  approaching  puberty.  She  had  had  four  attacks  of  pain  in 
the  right  iliac  fossa,  one  of  which  disappeared  suddenly  under  the  influence  of 
a  warm  rectal  enema,  and  the  others  spontaneously.  When  she  came  under 
observation  during  the  fourth  attack,  there  was  a  slight  elevation  of  tempera- 
ture with  pain  and  exquisite  tenderness  in  the  right  iliac  fossa,  and  a  sensitive 
tumor  just  above  Poupart's  ligament.  The  tenderness  and  the  tumor  both 
seemed  to  be  rather  too  far  down  for  the  appendix,  and  a  diagnosis  of  appendi- 
citis was  made  with  som.e  hesitation,  disease  of  the  uterine  adnexa  having  been 
considered  and  rejected.  Operation  showed  a  right  ovarian  cyst  the  size  of  a 
small  egg,  its  pedicle  twisted  by  three  complete  turns  and  showing  signs  of 
beginning  gangrene. 

Ruptured  Tubal  Pregnancy. — A  diagnosis  between  appendicitis  and  ruptured 
tubal  pregnancy  is  seldom  difficult,  if  an  accurate  history  of  the  events  leading 
to  the  attack  can  be  obtained,  as  well  as  a  clear  description  of  its  onset.  The 
history  of  irregular  menstruation,  especially  the  statement  that  a  period  has 
been  delayed  for  a  week  or  more  with  a  subsequent  slight  irregular  flow,  is 
strongly  suggestive  of  a  tubal  pregnancy.  The  onset  of  an  attack  with  sudden 
agonizing  pain  followed  almost  immediately  by  fainting  and  marked  pallor,  is 
pathognomonic.  Chills,  vomiting,  and  involuntary  evacuation  of  the  bowels 
may  occur  at  the  outset  of  either  a  ruptured  tubal  pregnancy  or  an  acute  per- 
forative appendicitis.     Tenderness  and  muscle  spasm  over  the  right  iliac  fossa 


592  APPENDICITIS    AND    DISEASES    OF    THE    PELVIC    OEGANS. 

ma  J  be  observed  in  a  right  tubal  preguancy ;  usually,  liowever,  the  local  signs 
are  situated  deeper  in  the  pelvis;  in  bimanual  examination  the  enlarged  tube 
can  generally  be  palpated.  Finally,  it  may  be  said  that  the  most  important 
point  in  arriving  at  a  correct  diagnosis  is  the  recognition  of  the  fact  that  con- 
fusion may  arise. 

APPENDICITIS    AND    DYSMENORRHEA. 

It  is  now  generally  acknowledged  that  chronic  inflammation  of  the 
appendix  is  often  associated  with  painful  menstruation.  Ochsner, 
writing  on  appendicitis  as  a  cause  of  inflammatory  disease  of  the  uterine  adnexa 
{Jour.  Amer.  Med.  Assoc,  1899,  vol  33,  p.  192),  makes  a  passing  allusion  to 
dysmenorrheas  arising  from  the  association  of  appendicitis  with  disease  of  the 
ovaries  or  tubes  on  the  right  side,  and  remarks  that  whenever  the  pain  in 
dysmenorrhea  is  entirely  on  the  right  side,  especially  if  it  is  situated  high  up, 
it  is  well  to  suspect  that  the  disturbance  of  the  appendix  is  complicated  with 
disturbance  of  the  ovaries. 

In  the  next  year  A.  MacLaren  published  an  interesting  paper  on  the  rela- 
tionship between  dysmenorrhea  and  chronic  appendicitis,  in  which 
he  emphasizes  the  fact  that  in  chronic  appendicitis,  menstruation  is  often  pain- 
ful without  any  disease  of  the  uterus  or  adnexa  (Amer.  Gyn.  and  Obst.  Jour., 
1900,  vol.  17,  p.  14).  He  calls  attention,  most  appropriately,  to  a  class  of  cases 
familiar  to  every  physician  of  experience,  in  which  a  young  girl,  who  has  men- 
struated for  several  years  without  any  disturbance  or  suffering  whatever,  sud- 
denly takes  cold  or  has  some  slight  inflammatory  symptoms,  after  which  she 
begins  to  suffer  with  the  menstrual  period,  the  pain  increasing  each  time  until 
her  nervous  system  is  more  or  less  shattered.  These  cases  are  usually  consid- 
ered to  be  neurasthenic,  and  there  is  no  doubt  that  many  of  them,  possibly 
the  majority  of  them,  are  so ;  but,  in  MacLaren's  opinion,  there  is  a  certain 
proportion  in  which  the  menstrual  pain  is  really  due  to  a  chronic  inflanunation 
of  the  appendix,  which  undergoes  a  slight  exacerbation  at  each  jDeriod,  on  ac- 
count of  the  congestion  normally  accompanying  every  menstruation.  In  some 
cases  the  chronic  appendicitis  exists  before  menstruation  begins,  and  then 
dysmenorrhea  is  present  all  through  menstrual  life,  until  the  appendicitis  is 
discovered  and  relieved. 

Other  contributions  to  this  subject  have  been  made  from  time  to  time,  but 
the  total  amount  of  information  concerning  it  is  small.  There  is  an  excellent 
discussion  of  the  subject,  however,  by  Soupault  and  Jouaust  in  a  paper  called 
"  Appendicite  larvee  et  des  troubles  menstruels  "  (Bull,  et  mem.  de  la  Soc.  med. 
des  hop.  de  Paris,  1903,  vol.  20,  p.  1307).  The  writers  begin  by  commenting 
on  the  fact  that  although  medical  literature  is  richly  supplied  on  other  points 
connected  with  the  appendix,  it  contains  scarcely  anything  on  its  relation  to 
dysmenorrhea.  Soupault  had  himself  observed  a  number  of  cases  of  menstrual 
pain  associated  with  appendicitis,  and  believed  that  they  presented  certain  char- 
acteristics which  should  aid  in  the  diagnosis. 


APPENDICITIS    AND    DTSMENOERHEA.  593 

In  dysmenorrhea  associated  with  appendicitis,  according  to  him,  the  suffer- 
ing begins  several  days  before  the  flow  is  due  and  reaches  its  maximum  just  as 
it  begins.  Sometimes  the  pain  disappears  suddenly,  as  if  by  magic,  as  soon  as 
the  flow  is  established ;  in  other  cases  it  lasts  through  menstruation,  diminishing 
gradually.  It  is  exceptional  for  the  attacks  of  pain  to  occur  at  each  menstrual 
period;  they  usually  accompany  menstruation  at  more  or  less  distant  intervals, 
without  any  definite  explanation  of  their  appearance  on  any  particular  occa- 
sion. The  intensity  of  the  suffering  varies  in  different  attacks  in  the  same 
person,  being  sometimes  so  slight  as  to  be  barely  perceptible,  while  at  other 
times  it  is  so  severe  as  to  be  unmistakable.  Occasionally,  though  rarely,  there 
are  symptoms  of  appendicitis  during  the  intermenstrual  periods,  and  when  this 
is  the  case  the  diagnosis  is  greatly  facilitated.  Gastro-intestinal  symptoms, 
especially  entero-colitis,  are  often  present  as  well  and  contribute  greatly  to  an 
understanding  of  the  case. 

Certain  other  signs  and  symptoms  observable  during  the  attack  are,  in 
Soupault's  opinion,  strongly  suggestive,  if  not  absolutely  diagnostic.  The  most 
constant  of  these  is  spontaneous  pain  situated  low  down  in  the  right  iliac  fossa 
and  limited  strictly  to  the  right  side.  It  is  rarely  lancinating  in  character, 
but  resembles  colic,  and  is  accompanied  by  a  sensation  of  discomfort  and  of 
pressure  in  that  locality.  The  pain  is  generally  intermittent  and  transient;  it 
yields  readily  to  mild  therapeutic  measures  and  usually  disappears  on  the  ap- 
pearance of  menstruation.  There  is  tenderness  on  pressure  over  the  right  iliac 
region,  but  not  by  any  means  always  over  McBurney's  point;  it  is  often  near 
the  umbilicus  or  it  may  be  in  the  groin,  in  which  case  it  is  liable  to  be  attributed 
to  the  right  ovary.  It  is  noticeable  that  the  tenderness  disappears  as  soon  as 
the  attack  is  over,  and  the  right  iliac  fossa  becomes  soft  and  painless  during 
the  intermenstrual  period.  The  abdominal  pain  is  almost  always  accompanied 
by  some  digestive  disturbance  which  lasts  only  a  short  time.  There  may  be 
nausea  and  vomiting,  at  first  of  food,  and  afterwards  of  bile.  The  presence  of 
diarrhea  and  vomiting,  either  separately  or  together,  is  of  great  diagnostic  im- 
portance. 

The  constitutional  symptoms  are  not  well  marked.  There  may  be 
a  little  headache,  pain  in  the  limbs,  and  shivering,  but  these  all  disappear  spon- 
taneously. The  point  of  great  importance  in  these  cases  is  the 
temperature.  When  taken  in  the  axilla  it  is  often  quite  normal,  when,  if 
taken  in  the  rectum  at  the  same  time,  there  will  be  some  elevation,  37.5°  to 
39°  0.  (99.5°  to  102°  F.).  The  pulse  shows  a  corresponding  acceleration, 
being  usually  about  100.  These  modifications  of  pulse  and  tempera- 
ture are  constant,  and  it  is  upon  them  that  the  diagnosis 
chiefly   rests. 

According  to  Soupault  the  association  between  menstrual  pain  and  appendi- 
citis may  be  explained,  in  some  cases,  by  the  fact  that  there  are  adhesions  be- 
tween the  appendix  and  the  adnexa  on  the  right  side,  in  which  blood  vessels 
and  lymphatics  develop,  and  these  become  easily  congested  under  the  influence 
39 


594  APPENDICITIS    XND    DISEASES    OF    THE    PELVIC    OEGAXS. 

of  menstruation.  In  other  cases,  where  no  adhesions  arc  present  and  the  ap- 
pendix lies  free  in  the  abdominal  cavity,  it  is  easy,  he  thinks,  to  explain  the 
congestion  by  means  of  vaso-motor  disturbances  affecting  an  organ  in  a  state  of 
lowered  resistance. 

Soupanlt  cites  seven  cases  of  dysmenorrhea  associated  with  appendicitis  out 
of  the  number  observed  by  him,  and  I  give  one  of  them  which  affords  a  good 
illustration  of  the  chief  diagnostic  points. 

Case  VII. — Miss  E.,  nineteen  years  old,  seamstress,  of  a  robust  appearance. 
She  had  always  had  good  health  and  had  menstruated  regularly  and  without 
suffering  until  a  year  before,  when  she  had  an  attack  of  abdominal  pain  limited 
to  the  right  side  and  accompanied  by  vomiting  of  a  greenish  character.  The 
attack  occurred  two  days  before  menstruation  and  lasted  forty -eight  hours,  sub- 
siding as  soon  as  the  menstrual  flow  appeared.  She  remained  in  bed  during  the 
menstrual  period,  and  then  got  up,  feeling  perfectly  well.  During  the  ensuing 
year  she  had  three  siiuilar  attacks  and  was  also  troubled  with  a  certain  amount 
of  entero-colitis,  with  mucous  stools.  At  the  end  of  nearly  a  year  she  had  a 
fourth  attack,  when  she  was  seen  by  Soupault.  Her  temperature  was  then 
39°  C.  (102°  F.)  ;  there  were  nausea,  bilious  vomiting,  diarrhea,  and  pain  on 
pressure  in  a  circumscribed  location  in  the  abdomen,  low  down  and  near  the 
groin.  These  symptoms  had  been  present  for  two  days  when  she  was  seen.  As 
soon  as  menstruation  appeared,  they  all  began  to  subside  and  disappeared  grad- 
ually as  menstruation  proceeded.  A  diagnosis  of  chronic  appendicitis  was  made 
and  laparotomy  performed  two  weeks  later,  when  the  appendix  was  found  to  be 
much  enlarged  and  surrounded  by  adhesions.  At  its  lower  end  there  was  a 
cavity  containing  a  suiall  quantity  of  malodorous  pus.  The  patient  had  no 
further  trouble  with  menstruation  and  the  entero-colitis  also  disappeared. 

In  many  cases  of  dysmenorrhea,  where  the  pain  is  entirely  on  the  right 
side,  it  is  well  to  suspect  appendicitis,  especially  if  the  patient  has  teen  free 
from  pain  in  the  early  years  of  menstrual  life.  If,  on  careful  observation  of 
the  attacks,  the  diagTiostic  points  given  by  Soupault  can  be  established,  namely, 
the  disappearance  of  pain  on  the  establishment  of  menstruation, 
or  at  any  rate  at  its  close,  the  presence  of  diarrhea  and  other  di- 
gestive symptoms,  and,  especially,  the  elevation  of  temperature 
when  taken  in  the  rectum,  it  is  tolerably  safe  to  conclude  that  the  case 
is  one  of  chronic  appendicitis  in  which  the  dysmenorrhea  is  merely  a  mani- 
festation. 

Tlje  only  class  of  cases  in  which  the  diagnostic  peculiarities  do  not  hold 
good,  in  Soupault's  oj^inion,  is  that  in  which  it  is  necessary  to  differentiate  be- 
tween an  inflamed  appendix  and  a  lesion  of  the  right  tube  and 
ovary  giving  rise  to  pain  in  menstruation.  The  symptoms  just  discussed  may 
be  foimd  in  such  cases  as  well  as  in  those  where  the  appendix  alone  is  at  fault, 
and  the  physician  must  depend  upon  the  history  of  the  individual  case  for  his 
differential  diagTiosis,  making  special  inquiry  as  to  the  possible  infection 
of    the    genitalia,    the    presence    of   menstrual    irregularities,    and 


APPENDICITIS    IN    THE  .CHILD.  595 

of  muoo-purulent  vaginal  discliarges.  One  point  of  importance  is  the 
fact  that  a  lesion  of  the  uterine  adnexa  rarely  remains  quiescent  between  the 
menstrual  periods,  while  in  the  class  of  cases  under  discussion  it  is  unusual 
to  find  any  expression  of  the  trouble  except  at  menstruation.  In  either  instance 
such  cases  belong  to  the  surgeon. 

Finally,  I  would  call  attention  to  the  fact  that  dysmenorrhea  is  some- 
times the  direct  result  of  acute  appendicitis.  An  inflammation  of 
the  appendix,  which  subsides  without  operation,  will  occasionally  be  followed 
by  dysmenorrhea,  when  the  patient  has  previously  been  free  from  menstrual 
suffering  altogether;  and  whenever  this  is  the  case,  the  presence  of  a  chronic 
appendicitis  should  be  suspected. 

The  treatment  of  dysmenorrhea  associated  with  appendicitis 
does  not  differ  from  that  of  dysmenorrhea  from  other  causes.  The  prominence 
of  the  digestive  symptoms  will  probably  call  for  remedial  measures.  For  the 
vomiting  I  know  nothing  better  than  the  prescriptions  given  already  for  use  in 
chlorosis  (see  p.  158)  ;  while  for  the  diarrhea  the  best  remedy  is  the  com- 
bination of  bismuth   and   paregoric. 

^  Bismuth,  subnit 3ij 

Tine.  opii.  camph fojss. 

Aq.  dest .  q.  s.  ad.  f ovj 

M.     S.   Shake  well  and  take  one  tablespoonful  every  four 
hours,  until  pain  subsides. 

The  question  of  operative  treatment  belongs,  of  course,  to  the  surgeon, 
to  whom  the  case  should  be  referred  without  loss  of  time.  It  would  seem  that 
this  is  a  class  of  cases  which,  as  Soupault  suggests,  is  peculiarly  suited  to  inter- 
val operation  (operation  a  froid)  during  the  intermenstrual  periods. 

APPENDICITIS    IN    THE    CHILD. 

It  may  not  be  out  of  place  here  to  say  a  few  words  in  regard  to  certain 
peculiarities  of  appendicitis  in  the  child. 

There  is  an  undoubted  etiologic  relation  between  intestinal  worms  and 
certain  forms  of  appendicitis  in  children.  Ascaris  is  the  variety  most  fre- 
quently found,  trichocephalus  next,  and  then  oxyuris.  The  frequency 
with  which  trauma  figures  in  the  causation  of  appendicitis  is  now  an  ac- 
cepted fact,  and  it  is  plain,  of  course,  that  with  children,  whose  activity  exposes 
them  especially  to  its  influence,  trauma  must  especially  be  often  a  causal  factor. 

The  diagnosis  of  appendicitis  in  children  is  frequently  obscure.  There  is 
sometimes  a  prodromic  stage,  in  which  there  is  more  or  less  of  gastro- 
intestinal disorder  without  any  signs  distinctly  suggestive  of  appendicitis.  In 
children  there  are  apt  also  to  be  misleading  symptoms  associated  with  the 
thoracic  viscera,  and  often  the  first  indication  of  appendicitis  in  a  child 
is  a    pneumonia,    a    pleurisy,    or  even  a    bronchitis.       The  examina- 


596  APPEIiTDICITIS    ANT)   piSEASES    OF    THE    PELVIC    OEGAlSrS. 

tion  of  a  cliilcl  for  appendicitis  should  never  be  considered  complete  without 
an  examination  of  the  chest. 

Another  notevorthv  point  in  the  early  diagnosis  of  appendicitis  in  children 
is  that  the  earlv  stage  of  it  is  apt  to  be  associated  in  them  with  disturbances 
of  motion.  A  few  cases  have  been  reported  in  which  the  first  symptom  ob- 
served was  a  difficulty  in  walking.  Dr.  R.  D.  Freeman,  of  South  Orange, 
IST.  J.,  reported  to  me  a  case  in  which  he  was  calling  upon  another  member  of 
the  family,  when  he  happened  to  notice  a  little  girl,  eleven  years  old,  who  was 
limping  as  she  played  tennis  in  the  yard  close  by  and  standing  in  a  position 
suggestive  of  hip  disease.  On  inquiry  it  was  found  that  she  had  complained 
for  a  few  days  of  indefinite  pain  in  the  lower  abdomen,  and  on  calling  her  into 
the  house  and  making  an  examination  a  tender  fluctuating  mass  was  found  in 
the  right  iliac  fossa.  The  right  leg  was  flexed  and  abducted,  there  were  muscu- 
lar rigidity  over  the  lower  abdomen  and  considerable  pain  on  pressure  over  and 
around  the  mass.  The  rectal  temperature  was  103°  F.,  and  the  pulse  90.  She 
had  had  no  considerable  pain  at  any  time  and  no  chill.  At  the  operation,  per- 
formed at  midnight  of  the  same  day,  a  large  abscess  surrounding  the  appendix 
was  evacuated  and  the  remains  of  a  sloughing  appendix  removed. 

V.  P.  Gibney  (Amer.  Jour.  Med.  Sci.,  1881,  vol.  81,  p.  119)  has  reported 
cases  of  appendicitis  mistaken  for  hip  disease,  and  several  striking  cases  of 
this  kind  have  come  under  the  observation  of  Drs.  W.  S.  Baer  and  J.  M.  T. 
Finney  of  Baltimore. 

An  examination  by  the  rectum  should  never  be  neglected  in  ap- 
pendicitis in  the  child,  since  the  index  finger  reaches  higher  in  the  infantile 
pelvis  than  in  that  of  the  adult,  and  thus  the  suspected  area  is  more  easily 
touched.  It  has  been  shown  that  in  almost  every  case  where  the  disease  has 
extended  beyond  the  appendix  the  extension  has  taken  place  along  the  right 
pelvic  wall,  where  the  inflammatory  mass  can  readily  be  felt.  In  making  his 
abdominal  examination,  the  surgeon  should  always  bear  in  mind  that  the  ad- 
hesions in  a  child  are  extremely  delicate,  and  more  than  ordinary 
care  must  be  exercised  in  order  to  avoid  rupturing  them.  A  case  has  been 
known  in  which  the  adhesions  around  a  localized  abscess  were  ruptured  during 
sleep,  and  another  in  which  rupture  took  place  during  an  effort  at  stool. 

Whenever  an  attack  of  appendicitis  in  the  child  is  suspected,  the  patient 
should  be  kept  in  bed  and  an  ice-bag  placed  over  the  abdomen.  The  diet 
should  be  liquid,  and  sufficient  opium  prescribed  to  keep  the  bowels  at 
rest.  It  is  of  the  utmost  importance  in  these  early  stages  to  avoid  active 
treatment,  such  as  purgatives  and  enemata,  which  are  calculated  to  do 
much  harm.  A  specialist  should  always  be  called,  if  possible,  as  soon  as  any 
suspicion  of  appendicitis  is  entertained.  Should  an  operation  be  performed,  the 
child  is  often  very  restless  after  its  performance,  and  to  keep  it  quiet  becomes  a 
difficult  matter.  Under  these  circumstances  a  Bradford  frame  affords  an 
excellent  means  of  assuring  relative  immobility  for  the  first  few  days,  while 
the  infected  area  is  being  walled  off  from  the  general  cavity  of  the  peritoneum. 


CHAPTER    XXy, 

(1)  SPLANCHNOPTOSIS— ENTEROPTOSIS—GLENARD'S   DISEASE. 
(2)  MOVABLE   KIDNEY. 

(1)  Splanchnoptosis — Enteroptosis — Glenard's  disease,  p.  597. 

(2)  Movable  kidney:  Anatomy,  p.  605.     Amount  of  normal  and  abnormal  mobility,  p.  606. 

iStiology,  p.  606.     Frequency,  p.  608.     Palpation  of  kidney,  p.  609.     Symptoms,  p.  610. 
Differential  diagnosis,  p.  613.     Treatment,  p.  617. 

SPLANCHNOPTOSIS— ENTEROPTOSIS— GLENARD'S    DISEASE. 

SpLAJsrcHJsroPTOSis,  from  the  Greek  words  signifying  descent  of  the 
viscera,  has  been  much  studied  during  the  past  few  years.  The  original  term 
enteroptosis  should  be  used  according  to  its  etymology  to  signify  descent 
of  the  intestines,  although  it  is  used  by  most  people  as  a  synonym  for 
splanchnoptosis,  that  is,  to  mean  descent  of  all  the  abdominal  viscera.  In 
designating  the  special  form  of  descensus  we  use  special  terms,  thus:  gas- 
troptosis,  of  the  stomach  ;  hepatoptosis,  of  the  liver  ;  neph- 
roptosis, of  the  kidneys  ;  splenoptosis,  of  the  spleen,  and  colop- 
tosis,  of  the  colon.  In  Figure  158  I  have  given  an  illustration  of  the 
various  visceral  ptoses  based  in  part  on  a  series  of  splendid  studies  made  by 
Clark  and  Pancoast  of  Philadelphia. 

To  the  anatomists  and  pathologists  we  owe  the  first  recognition  of  the  dis- 
ease, Morgagiii  being  the  first  to  describe  the  condition  anatomically,  while 
Virchow,  in  1853,  called  attention  to  displacement  of  the  intestines,  ascribing 
the  condition  to  partial  peritonitis,  and  regarding  its  mechanical  effects  as 
the  starting  point  of  a  number  of  cases  of  dyspepsia  and  indigestion.  Among 
the  older  clinicians,  Aberle,  Payer,  Rollet,  and  Oppolzer  referred  to  the  rela- 
tion between  hysteria  and  floating  kidney,  and  Kussmaul  called  attention  to 
the  symptoms  due  to  change  in  form  and  position  of  the  stomach. 

It  was  Glenard,  however,  the  distinguished  physician  of  Lyons,  whose 
work  at  the  adjacent  health  resort  of  Vichy  brought  him  in  contact  with  many 
cases  of  digestive  disturbance,  who  first  aroused  general  interest  in  this  condi- 
tion. The  disease  is  therefore  often  spoken  of  as  Glenard's  disease.  Glenard 
believed  that  in  enteroptosis  he  had  found  the  anatomic  basis  for  one  type  of, 
so-called,  nervous  dyspepsia. 

Anatomy. —  To  go  into  the  anatomy  of  the  abdominal  viscera  is  not  within 
the  scope  of  the  present  work.  Suffice  it  to  say  that  they  are  held  in  posi- 
tion by  a  number  of  different  forces:  by  the  negative  pressure  of  the 
thoracic  cavity  acting  through  the  diaphragm;  by  vascular,  peritoneal 

597 


598 


SPLANCHNOPTOSIS ENTEKOPTOSIS GLENAKD  S    DISEASE. 


and  ligamentous  attachments;  by  the  pressure  of  the  different 
organs  upon  each  other;  and  by  the  supporting  power  of  the  abdominal 
muscles. 


Fig.  158. — Composite  PicxrRE  from  over  100  Skiagraphs  in  Possession  of  Dr.  H.  K.  Paxcoast, 
OF  Philadelphia,  showing  Displacement  Doavnward  of  all  the  Abdominal  Organs  as  the 
Result  of  Constriction  of  the  Lower  Thorax.  The  liver  shows  Riedel's  lobe  ;  the  stomach  has 
descended  into  the  pelvis,  carrj^ing  the  transverse  colon  with  it.  Note  the  hour-glass  contraction  of 
the  fundus  of  the  stomach.  The  right  kidney  has  descended  moderately.  (From  forthcoming 
"  Surgery  of  the  Kidney,"  by  H.  A.  Kelly.) 


Xormally,  however,  no  organ  is  absolutely  fixed,  each  being  capable  of 
slight  movements  due  to  various  physical  factors,  such  ns  the  position  of  the 
patient,  the  amount  of  food  ingested,  the  passage  of  urine  and  feces,  and  the 
respiratory  and  circulatory  movements. 


ETIOLOGY    AND    SYMPTOMS.  599 

In  advanced  cases  of  splanchnoptosis  the  position  of  the  viscera  very 
closely  resembles  that  seen  in  embryonic  life,  and  this  is  regarded  by  some  per- 
sons as  an  argument  in  favor  of  the  congenital  origin  of  the  condition. 

Etiology. — As  regards  the  pathogenesis  of  splanchnoptosis  very  divergent 
views  are  held,  some  authorities  maintaining  that  the  condition  is  congenital, 
others  that  it  is  acquired,  while  others  again  hold  a  middle  ground.  Glenard 
believes  that  the  first  step  in  the  condition  is  a  falling  of  the  right  colic 
flexure,  due  to  a  weakening  of  thethepato-colic  ligament;  it  may  follow  preg- 
nancies, strains,  injuries,  abdominal  operations,  wasting  dis- 
eases, appendicitis,  etc.,  but  it  is  primarily  due  to  a  constitutional  defect 
affecting  the  strength  and  supporting  powers  of  the  mesenteric  tissues.  Stiller 
believes  that  there  is  a  characteristic  sign  of  the  condition  in  the  floating  tenth 
rib,  while  Mathes  states  well  the  congenital  theory,  when  he  says  "  splanch- 
noptosis is  a  constitutional  hereditary  anomaly  of  the  entire  organism,  a  lack 
of  vital  energy  in  all  the  vital  tissues." 

Many  persons  believe  that  the  condition  is  acquired,  not  based  on  a  con- 
genital defect,  and  as  special  causes  of  the  condition  they  mention 
the  wearing  of  tight  belts  and  corsets,  pregnancy  and  parturition, 
wasting  diseases,  the  removal  of  abdominal  tumors  or  of  ascitic 
fluid — in  fact,  any  condition  which  tends  to  increase  the  pressure  above  the 
abdominal  organs,  decrease  the  pressure  below  them,  or  diminish  the  size  or  the 
expansile  power  of  the  lower  thoracic  zone.  According  to  Keith,  who  has  done 
much  work  on  this  subject,  splanchnoptosis  is  the  result  of  a  vitiated  method 
of  respiration,  and  should  be  assigned  to  a  place  among  the  respiratory  diseases ; 
he  believes  that  the  contraction  of  the  diaphragm,  especially  the  crura,  is  the 
most  important  agent  in  producing  the  displacement,  although  before  this 
descensus  takes  place,  either  the  thoracic  supports  of  the  diaphragm  must  have 
yielded,  or  the  antagonistic  abdominal  muscles  been  hampered  or  weakened, 
as,  for  example,  by  tight  corsets.  A  study  of  a  large  number  of  cases  has 
convinced  me  that,  although  the  condition  may  be  acquired  in  a  number  of 
cases,  in  the  majority,  the  underlying  cause  is  a  definite  con- 
genital defect,  and  that  this  latent  predisposition  is  fanned  into 
the  actual  disease  by  some  malady  of  an  exhausting  nature,  such 
as  conditions  associated  with  loss  of  weight,  especially  if  rapid ;  conditions  which 
produce  sudden  changes  in  the  intra-abdominal  pressure ;  lack  of  proper  nourish- 
ment; and  increased  pressure  in  the  lower  thoracic  zone,  as  by  tight  lacing. 

Symptoms. — The  symptoms  of  splanchnoptosis  are  extremely  varied. 
On  the  one  hand,  there  may  be  no  symptoms  whatsoever,  while  on  the  other, 
the  symptom-complex  may  be  more  protean  and  complex  than  in  almost  any 
other  condition.  Certain  symptoms  are  especially  referable  to  the  ptosis  of 
the  special  viscera,  while  other  symptoms  are  dependent  upon  the  degree 
of  involvement  of  the  nervous  system.  As  to  the  relation  between 
neurasthenia  and  splanchnoptosis  there  is  a  wide  divergence  of  opinion, 
some  holding  that  the  neurasthenia  is  essential,  the  splanchnoptosis 


600  SPLA^^CHNOPTOSIS EKTEEOPTOSIS GLENAED  S    DISEASE. 

incidental,  others  the  reverse  view,  while  still  a  third  group  believes,  and  I 
think  rightly,  that  in  most  cases  each  condition  represents  a  congenital  fragility 
of  tissue,  independent,  primarily,  of  the  other,  hut  reacting  very  deleteri- 
ously  upon  it,  moreover  the  two  are  frequently  associated.  The  picture  usu- 
ally presented  is  that  of  a  thin,  pale,  young  man  or  woman  with  a  deficient 
amount  of  fat,  a  nervous  and  worried  expression,  a  long  thorax  constricted 
in  its  lower  half,  and  thin,  soft  abdominal  walls,  who  complains  of  many 
dyspeptic  and  nervous  symptoms  and  sometimes  of  pain  in  various  portions  of 
the  abdomen  as  well.  The  patient  often  complains  of  a  feeling  of  lack  of 
abdominal  support,  and  sometimes  of  a  loose  body  in  the  abdominal  cavity. 
Glenard  himself  divides  the  symptoms  into  three  special  groups — lack  of  tone 
of  the  abdominal  walls,  descent  of  the  various  abdominal  vis- 
cera, and  a  stenotic  condition  of  the  large  intestines.  Others 
have  paid  especial  attention  to  the  respiratory  and  circulatory  symptoms, 
dyspnoea,  asthmatic  attacks,  etc. 

As  to  symptoms  referable  to  a  special  organ  it  must  be  remembered  that 
in  many  cases  they  are  due  to  the  displacement  of  several  viscera,  not  of  one, 
but  the  author  sometimes  loses  sight  of  other  ptoses,  and  ascribes  all  the  symp- 
toms to  the  descensus  of  the  organ  he  is  especially  studying.  This  is  peculiarly 
the  case  in  displaced  kidney,  for  many  of  the  symptoms  ascribed  to  this  con- 
dition are  in  reality  due  to  descensus  of  the  stomach  or  of  the  intestines ;  while 
our  gynecological  brethren  should  remember  that,  in  many  cases,  retroflexion 
or  retroversion  of  the  uterus  is  but  a  part  of  a  general  splanchnoptosis,  the  vast 
majority  of  the  symptoms  ascribed  to  the  displaced  uterus  being  in  reality  due 
to  the  displacement  of  other  organs.  Under  these  conditions,  the  expectation 
of  relief  from  all  symptoms  by  suspending  the  kidney  or  the  uterus  is  abso- 
lutely without  foundation,  and  is  based  on  a  complete  misconception  of  the  facts. 

Symptoms  especially  associated  with  the  stomach  are  the  splashing  sound, 
which  is  often  heard,  and  others  referable  either  to  the  associated  atony 
of  the  stomach  wall,  or  to  the  dilatation,  which  so  frequently  accom- 
panies gastroptosis,  and  the  associated  anomalies  of  gastric  secre- 
tion. In  cases  of  displacement  of  the  stomach,  especially  of  the 
vertical  and  subvertical  type,  gastrectasy  is  very  likely  to  occur  with  its  char- 
acteristic symptom-complex,  particularly  if  the  patient  indulges  in  frequent 
indiscretions  of  diet,  while  in  gastroptosis  subacidity  is  the  rule,  the  degi-ee 
of  diminution  of  the  free  hydrochloric  acid  depending  upon  the  extent  of  the 
associated  dilatation. 

Of  symptoms  especially  referable  to  movable  kidney  alone  may  be  men- 
tioned Dietl's  crises,  intermittent  hydronephrosis,  hepatic  colic, 
due  to  pressure  on  the  duct,  pain  either  dull  and  constant,  or  intermit- 
tent, and  the  feeling  of  a  floating  body  in  the  abdomen,  due  prob- 
ably to  congestion  of  the  kidney,  while  recently  many  persons  have  called 
attention  to  the  frequent  association  which  seems  to  exist  between  right 
floating  kidney    and   chronic   appendicitis. 


DIAGNOSIS.  601 

As  regards  the  liver,  hepatalgia,  hepatic  colic,  gall-stone  at- 
tacks, asthma,  and  the  sensation  of  a  floating  body  have  been 
ascribed  to  this  organ's  displacement. 

A  movable  spleen  often  gives  rise  to  sensations  of  dragging  and 
pain  and  the  patient  is  almost  always  conscious  that  a  body  of  some  kind 
is  moving  about  in  the  abdominal  cavity.  The  symptoms,  in  fact, 
are  exactly  similar  to  those  of  a  displaced  kidney.  In  my  own  cases  this 
movability  of  the  spleen  has  not  been  associated  with  a  general  splanchnoptosis. 

Symptoms  definitely  referable  to  displacement  of  the  intestines  are  in- 
testinal fermentation,  intestinal  pain,  mucous  colitis,  and  con- 
stipation. 

Diagnosis. — The  diagnosis  of  the  condition  is  easily  made ;  the  characteristic 
expression  and  body  form,  the  long  flat  chest,  the  weakened  abdominal  muscles, 
and  the  protean  symptom-com- 
plex should  at  once  attract  our  I 
attention.  In  diagnosing  gas-  r\ 
troptosis  the  best  methods  are  '  \  1 
percussion,  combined  as  a  rule  I  I  \ 
with  inflation  of  the  organ  \  /  \ 
by  means  of  carbon  dioxide  gas  |  /  "^"^-^-^ 
or  through  a  stomach  tube  (see  I  ^^  ,  i 
Fig.  159),  or,  more  accurately  /  t  X  )  ^.--— •"""^'"^ 
still,  by  the  use  of  the  X-rays  /  vll^"  'W 
after  making  the  patient  swallow  I  I  <* 
a  bismuth  emulsion.  In  case  of  ^  ^  |  '^  • 
nephroptosis  we  use  palpa-  ,  .  /  ;-x  i  f 
tion,  examining  the  patient  in  -•  V  |  j'j 
both  the  prone  and  the  upright  '^x.  •  \,,  "^--X^-^Jt..---^  . 
position,  and  I  have  shown  \^  ^ — ;— -^  /  ^-AjJ  '  j 
(Amer.  Jour.  Obst.,  1899,  voL  I  v  ^  i 
40,  p.  328)  that  a  characteristic      ^— -            -' 

Dietl's     crisis    may    be     produced        ^ig.  159.-Gauze  Record ^ofJWarked  Displacement 

by  injecting  fluid  into  the  renal 

pelvis  through  a  urethral  catheter;  in  the  case  of  the  liver  we  make  use  of 
palpation,  percussion  and  inspection,  always  being  careful  to  do  so 
with  the  patient  in  both  the  prone  and  the  upright  positions,  also  deter- 
mining, as  in  the  case  of  the  kidney,  whether  the  organ  can  be  replaced  in 
its  normal  position  by  manipulation;  in  the  case  of  the  spleen  we  palpate 
with  the  patient  standing  and  the  patient  lying  down,  while  in  the  case 
of  the  intestines  inspection  of  the  peristaltic  movements,  palpa- 
tion of  the  stenosed  portions  of  the  intestine,  inflation  through 
a  rectal  tube,  or  X-ray  photography  after  the  injection  of  bismuth 
emulsion  gives  us  the  diagnosis. 

Most  of  these  patients  give  the  so-called    belt    test    of  Glenard;  that  is. 


602  SPLANCHNOPTOSIS ENTEK.OPTOSIS GLENARD's    DISEASE. 

the  sjmjDtoms  are  much  relieved  if  the  physician  stands  behind  the  patient  and 
lifts  up  the  loAver  abdomen  with  his  hands,  while  in  most  cases  the  symptoms 
are  markedly  ameliorated  by  the  assumption  of  the  prone  position.  The  char- 
acteristic body  form  has  been  studied  mathematically  by  Harris  and  others, 
who  have  given  a  formula  expressed  in  terms  of  various  body  diameters,  which 
will  tell  whether  splanchnoptosis  is  likely  to  be  met  with. 

Frequency. — The  condition  is  extremely  common,  as  shown  by  the  fact  that 
Glenard  finds  it  in  one  out  of  every  five  women  who  come  to  Vichy,  and  in 
one  out  of  every  forty  men,  while  Einhorn  finds  the  condition  in  six  per  cent 
of  males,  and  thirty-five  per  cent  of  females ;  of  course,  it  must  be  remembered 
that  most  of  the  patients  who  consult  these  physicians  are  suffering  with  digest- 
ive disorders,  and  the  percentage  is  consequently  considerably  higher  than  that 
which  would  be  obtained  in  a  general  clinic,  although  Thorndike  has  recently 
found  the  condition  a  hundred  and  twelve  times  in  two  hundred  and  seventy- 
two  general  patients  in  Boston.  As  regards  pregnancy  a  series  of  several 
hundred  cases  shows  that  about  fifty  per  cent  had  borne  children,  about  fifty 
per  cent  had  not ;  as  regards  involvement  of  the  two  kidneys,  of  seven  hundred 
and  twenty-seven  cases  of  renal  displacement,  the  right  alone  was  involved  five 
hundred  and  fifty-three  times,  the  left  alone  eighty-one  times,  and  both  ninety- 
three  times. 

Treatment. — The  most  practical  and  the  most  important  division  of  the  sub- 
ject is  that  devoted  to  the  prevention  and  treatment  of  the  condition.  In 
discussing  the  prophylaxis  of  splanchnoptosis  we  should  keep  in  mind  that 
the  majority  of  such  patients  have  a  congenital  tendency,  which  brings  about 
marked  displacement  of  the  various  viscera,  however,  only  after  they  have  been 
exposed  to  various  secondary  influences.  For  this  reason  it  is  extremely 
important  that  persons  with  the  characteristic  body  form,  especially  children, 
should  be  guarded  with  great  care ;  they  should  be  made  to  rest  at  certain  times, 
especially  after  meals ;  everything  should  be  done  to  increase  their  bod}^  weight ; 
carefully  selected  exercises  should  be  employed  to  strengthen  their  abdominal 
muscles,  and  massage  should  be  given.  They  should  be  taught  breathing  and 
standing  exercises  so  that  their  lower  thoracic  zone  may  be  strengthened  as 
regards  its  muscles,  and  increased  as  regards  its  volume.  Careful  attention 
should  be  paid  to  everyone  during  and  after  acute  and  chronic  diseases,  espe- 
cially if  associated  with  much  loss  of  weight,  after  the  removal  of  abdominal 
tumors  or  ascitic  fluid;  and  after  childbirth.  In  these  last  three  conditions 
it  is  absolutely  essential  that  an  abdominal  bandage  be  worn  until  normal 
intra-abdominal  pressure  relations  obtain  again.  We  should  especially  insist 
upon  the  danger  from  wearing  tight  belts  and  tight  corsets,  especially  those 
where  the  pressure  is  applied  in  the  hypochondriac  and  upper  abdominal 
regions. 

As  to  the  treatment  proper  of  splanchnoptosis  it  may  be  divided  into 
three  groups:  (1)  Treatment  by  medicine,  diet,  and  general  hy- 
gienic measures,   including  rest,   exercise    and   massage  ;    (2)    treat- 


TREATMENT. 


603 


ment  by  bandages,  pads,  plasters,  belts  and  supports  of  various 
kinds;  (3)  operative  treatment.  In  regard  to  treatment  it  seems  to  me 
that  splanchnoptosis  in  the  majority  of  cases  should  be  treated  by  medi- 
cal, hygienic  and  mechanical  means,  while  operative  treatment 
should  only  be  used  where  the  symptoms  are  definitely  referable  to  the  dis- 
placement of  an  especial  organ,  or  where,  although  the  symptoms  cannot  be 
definitely  referred  to  any  special  organ,  all  other  means  of  treatment  have 
proven  failures. 

Treatment  by  medicine,  diet  and  general  hygienic  measures 
is  of  extreme  importance  in  splanchnoptosis.  As  to  the  diet  this  depends  largely 
upon  the  condition  of  the  stomach,  and  whether  or  not  atony  and  dilatation  are 
present.  Usually  a  simple  mixed  dietary  is  advisable,  with  rather  small 
meals  and  often  extra  food  in  the  shape  of  raw  eggs  and  milk  between  meals ; 
fluids  had  best  be  taken  in  very  small  amounts  while  eating ;  in  some  cases  a 
dry-meat  and  stale-bread  diet  is  advisable,  while  in  a  number  of  instances 
where  the  nervous  symptoms  were  well-marked,  I  have  obtained  excellent  results 
by  treating  the  patient  as  in  neurasthenia  with  systematic  over-feeding  begun 
by  rest  and  an  absolute  milk  diet. 

As  regards  medicines  these  are  but  little  indicated;  iron  and  arsenic 
for  the  anemia,  strychnin  as  a  general  nerve  tonic,  alkalies  to  lessen  the 
gastro-intestinal  fermentation,  hydrochloric  acid  if  the  stomach  shows  de- 
ficiency in  this,  are  indicated  in  this  condition ;  while  for  the  constipation 
aloes,  cascara  or  the  salines  may  be' used,  if  successful  results  are  not 
obtained  by  the  use  of  enemata,  especially  those  of  oil,  or  by  massage, 
electricity,  hydrotherapy,  and  exercise.  Lavage  is  indicated  in 
case  of  gastrectasy. 

Rest  is  extremely  important,  especially  in  those  eases  deficient  in  weight; 
this  is  peculiarly  advisable  after  meals.  In  some  cases  a  systematic  rest  cure 
has  produced  wonderful  results  in  my  experience.  Massage  both  general 
and  abdominal,  systematic  exercises,  especially  those  designed  to  de- 
velop the  abdominal  and  thoracic  muscles,  hydrotherapy  and  electricity, 
are  all  of  value. 

Treatment  by  bandages,  pads,  plasters,  belts  and  supports  of 
various  kinds  should  always  be  tried  in  splanchnoptosis;  the  object  of  these 
is,  of  course,  twofold:  to  increase  the  intra-abdominal  pressure,  and  to  decrease 
the  size  of  the  lower  half  of  the  abdominal  cavity.  They  should  always  be  ap- 
plied with  the  j)atient  on  the  back  with  the  hips  elevated,  so  that  the  organs  will 
have  fallen  back  into  approximately  their  normal  positions,  and  the  direction 
of  the  pressure  should  always  be  from  below  upwards  and  backwards.  Among 
various  abdominal  bandages  may  be  mentioned  the  elastic  bandage  of  Glenard, 
Longstreth's  belt,  Gallant's  special  corset,  and  Rose's  method  of  bandaging  with 
adhesive  plaster.  Some  authors  advise  the  use  of  pads,  especially  for  support- 
ing the  liver,  the  kidney,  and  the  stomach,  but  in  my  experience  these  have  not 
proven  satisfactory. 


604  SPLANCHNOPTOSIS ENTEROPTOSIS GLENAED  S    DISEASE. 

Operative  treatment,  as  we  have  said  before,  sliould  only  be  used  in 
those  cases  where  the  symptoms  are  definitely  referable  to  the  displacement  of 
an  especial  organ,  as,  for  example,  Dietl's  crises  in  nephroptosis,  or  in  those 
cases  where  medical,  hygienic  and  mechanical  means  have  been  tried  without 
success.  As  to  the  objects  of  the  operation,  they  are  in  the  main  to  fix  the 
organ  in  approximately  the  normal  position,  and  at  the  same  time  to  allow  a 
slight  degree  of  mobility. 

In  the  case  of  the  kidney  the  old  forms  of  nephropexy  have  been  aban- 
doned, such  as  suture  through  the  perirenal  fat,  through  fat  and  capsule, 
through  a  capsule  which  has  been  previously  split  and  partially  dissected, 
through  the  kidney  substance,  and  packing  the  kidney  so  that  strong  adhesions 
may  form.  I  call  attention  especially  to  the  value  of  the  Brodel  stitch  in 
nephropexy,  as  its  holding  power  is  from  two  and  a  half  to  three  times  that 
of  the  ordinary  stitch. 

In  the  case  of  the  stomach  various  operations  have  been  devised,  such  as 
fixation  of  the  stomach  to  the  anterior  abdominal  wall,  fixation  to  the  dia- 
phragm, lifting  the  colon  by  fixing  both  its  flexures  to  the  abdominal  wall, 
various  procedures  to  shorten  the  stomach  ligaments,  and  Coffey's  operation  of 
slinging  the  stomach  in  a  hammock  made  of  omentum;  of  these  Beyea's  gas- 
tropexy  has  probably  given  the  best  results. 

In  the  case  of  the  liver  stitching  the  organ  to  the  thoracic  or  abdominal 
wall  and  the  formation  of  adhesions  by  irritating  the  surface  of  the  liver  have 
been  advised. 

In  the  case  of  the  spleen  operation  is  rarely  necessary,  but  if  torsion  with 
pain,  swelling,  and  possible  gangTene  occurs,  splenectomy  should  be  done. 

In  the  case  of  the  intestines  numerous  operations  have  been  done  re- 
cently :  sigmoidopexy  or  even  resection  of  the  sigmoid ;  in  some  cases  resection 
and  anastomosis  of  the  colon,  and  in  some  cases  resection  of  the  abdominal  wall 
where  there  is  a  marked  diastasis  of  the  recti  muscles. 


ANATOMY    OF    TIIE    KIDNEYS.  gQS 


MOVABLE    KIDNEY. 

Anatomy. — It  will  probably  be  wisest  at  the  very  outset  to  recall  briefly 
those  anatomical  conditions  abont  the  kidney  which  are  indispensable  to  a 
thorongh  understanding  of  the  anatomy  and  the  anatomical  relations  of  the 
kidney  in    nephroptosis    or    movable    kidney. 

The  kidneys  are  bean-shaped  organs  weighing  about  four  ounces  in  the  fe- 
male and  a  little  more  in  the  male,  and  placed  retroperitoneally  in  the  loin  on 
each  side  of  the  spinal  column.  Each  kidney,  measured  roughly,  is  four  inches 
long,  two  and  a  half  inches  broad,  and  one  and  a  quarter  inches  thick,  and  pos- 
sesses an  anterior  and  a  posterior  surface,  an  outer  and  an  inner  border,  and 
an  upper  and  a  lower  convex  extremity. 

The  direction  of  the  kidneys  is  not  exactly  vertical,  but  rather  down- 
ward and  slightly  outward,  with  their  anterior  surfaces  looking  forward  and 
outward,  while  their  posterior  surfaces  look  backward  and  inward.  The  outer 
border  is  convex,  while  the  inner  border  is  concave  and  forms  the  hilum  where 
the  vessels  and  ureter  join  the  kidney.  The  upper  end  of  each  kidney  lies  in 
the  hypochondriac  and  epigastric  regions,  and  the  lower  pole  projects  into  the 
adjacent  portions  of  the  umbilical  and  lumbar  regions.  They  extend  from 
about  the  level  of  the  eleventh  dorsal  to  the  second  or  third  lumbar  vertebra, 
and  are  thus  within  about  two  inches  of  the  iliac  crest.  The  right  kidney 
is  placed  a  little  lower  than  the  left,  possibly  on  account  of  the  position  of 
the  liver. 

The  kidney  possesses  several  coverings  or  capsules  of  different  struc- 
ture and  consistency,  all  of  which  probably  play  an  important  part  in  maintain- 
ing the  organ  in  its  proper  position.  Snugly  encasing  the  kidney  parenchyma 
is  its  own  true  capsule,  a  thin,  smooth  membrane  composed  mostly  of  fibrous 
and  elastic  tissue.  ^Normally  this  capsule  is  not  firmly  united  to  the  kidney 
proper,  and  unless  there  has  been  previous  inflammation,  it  can  be  easily 
stripped  ofl^.  The  kidney  with  its  fibrous  capsule  is  next  surrounded  by  a  layer 
of  fat,  the  fatty  capsule  or  "tunica  adiposa."  This  fatty  capsule  is 
permeated  by  fine  elastic  fibres  and  cellular  tissues,  which  unite  it  to  the  adja- 
cent inner  and  outer  coverings.  The  union  between  the  fibrous  and  the 
fatty  capsules  is,  however,  very  delicate  and  they  can  be  easily  separated 
unless  there  has  been  some  previous  pathological  change.  The  amount  of  fat 
varies  in  different  locations,  being  more  abundant  posteriorly  upon  the  convex 
border,  at  the  hilum,  and  just  below  the  lower  pole,  while  anteriorly  there  is 
comparatively  little.  The  perinephritic  adipose  layer  is  not  marked  before 
the  tenth  or  twelfth  year  of  life.  The  tunica  adiposa  has  a  peculiar 
"  canary-yellow "  color,  which  is  easily  distinguished  from  contiguous  sub- 
peritoneal fat  and  acts  as  a  valuable  landmark  in  renal  surgery. 

We  have  described  from  within  outward  the  kidney  proper,  the  fibrous 


606  MOVABLE    KIDNEY. 

capsule,  tlic  tunica  adiposa,  and  we  now  come  to  the  last  structure, 
which  is  of  especial  interest  in  its  relation  to  movable  kidney;  that  is,  the 
perinephritic  fascia,  sometimes  called  Gerota's  capsule.  This  is  a 
firm,  fibrous  covering,  composed  of  an  anterior  and  a  posterior  layer,  which 
meet  above  and  to  the  outer  side  of  the  perirenal  fat,  but  do  not  fuse  below  or 
anteriorly.  Thus  in  a  kidney  of  abnormal  mobility  the  path  of  least  resistance 
is  downward  and  inward. 

As  mentioned  above,  the  kidneys  are  placed  retroperitoneally,  only  portions 
of  their  anterior  surface  coming  in  contact  with  the  peritoneum. 

Amount  of  Normal  and  Abnormal  Mobility. — Some  writers  attempt  to  classify 
movable  kidney  according  as  it  has  or  has  not  a  mesentery,  but  any  classi- 
fication I  make  here  will  be  based  entirely  upon  clinical  and  not  upon 
anatomical  findings.  Each  kidney  moves  to  some  extent  with  respira- 
tion, descending  during  inspiration  and  ascending  during  expiration.  This 
movement  usually  occurs  within  the  fatty  capsule,  though  in  some  cases  the 
fatty  capsule  itself  moves  to  a  slight  extent  within  the  perinephritic  fascia, 
or  movement  may  occur  in  both  at  the  same  time.  What,  then,  should  we 
consider  a  normal  and  what  an  abnormal  mobility?  Upon  this  point 
there  is  a  wide  variance  of  opinion  among  writers,  but  all  agree  that  any  kidney 
whose  range  of  mobility  is  less  than  one  and  a  half  inches  should  not  be  con- 
sidered abnormally  movable.  It  is  also  generally  held,  and  probably  correctly 
so,  that  the  normal  movement  is  slightly  more  in  women  than  in  men.  An 
explanation  for  this  is  given  in  the  different  shapes  of  the  renal  fossae  in  the 
two  sexes. 

The  terms  used  to  designate  the  degrees  of  abnormal  mobility  are 
various  and  often  confusing.  I  prefer  to  stick  to  the  three  simple  terms, 
palpable,  movable,  and  floating  (see  Fig.  160).  By  palpable  we 
mean  those  cases  where  less  than  half  of  the  kidney  can  be  felt  on  deep  inspira- 
tion. Movable  includes  those  eases  where  half,  two-thirds,  or  even  all  of  the 
kidney  can  be  felt,  but  where  it  cannot  be  displaced  to  any  other  portion  of  the 
abdomen.  Floating  includes  those  cases  in  which  the  kidney  can  be  grasped 
and  brought  up  to  the  abdominal  wall  or  carried  to  some  other  portion  of  the 
abdomen. 

Although  this  classification  is  entirely  clinical,  it  furnishes  a  good  working 
basis.  For  instance,  if  a  patient  comes  with  abdominal  symptoms  resembling 
those  which  we  should  naturally  expect  to  find  with  a  freely  movable  kid- 
ney, and  upon  examination  the  kidney  is  found  to  be  simply  palpable,  the 
chances  are  that  it  is  not  the  cause  of  the  symptoms.  Whereas,  if  the  kidney  is 
found  movable  or  floating,  the  physician  must  seek  diligently  to  find  some 
connection  between  the  abnormal  renal  mobility  and  the  symptoms  of  which  the 
patient  complains. 

Etiology. — Upon  no  other  phase  of  movable  kidney  is  there  so  much  differ- 
ence of  opinion  or  lack  of  any  absolute  proof  as  upon  its  etiology.  If  half  a 
dozen  prominent  physicians  were  asked  to-day  what  they  considered  to  be  the 


ETIOLOGY. 


607 


one  most  important  factor  in  the  causation  of  movable  kidney,  they  would 
probably  all  give  different  answers. 

Glenard  maintained  that  movable  kidney  was  not  a  clinical  entity  at  all, 
but  simply  part  of  the  general  condition  of  enteroptosis,  and  he  is  credited 
with  the  statement  that  "  enteroptosis  can  be  present  without  nephroptosis,  but 


Fig.  160. — Showing  Three  Degrees  of  Displacement  of  the  Kidney.  In  the  first  degree  (palpable) 
the  lower  pole  is  only  just  perceptible  to  the  touch.  In  the  second  degree  (movable)  the  upper  pole 
just  emerges  from  under  the  costal  margin.  In  the  third  degree  (floating)  the  entire  kidney  can  be 
palpated. 


never  nephroptosis  without  enteroptosis,"  a  statement  which  clinical  observa- 
tions do  not  confirm,  for  unquestionably  there  are  cases  of  movable  or  even 
floating  kidney  in  which  no  displacement  of  other  organs  can  be  discovered. 

Becker  and  Lennhoff  were  the  first  to  definitely  emphasize  the  great  impor- 
tance of  body-shape  as  an  etiological  factor  in  nephroptosis.  These  writers 
maintained  that  the  vast  majority  of  persons  having  a  movable  kidney  had 
also  a  peculiar  form  of  chest  and  abdomen  which  was  somewhat  cone- 
shaped  in  appearance,  with  the  apex  pointing  downward;  while  those  cases  in 
which  there  was  no  nephroptosis  presented  rather  a  cylindrical  appearance. 
To  be  more  accurate,  they  measured  the  distance  from  the  suprasternal  notch 


608  MOVABLE    KIDNEY. 

to  the  tojD  of  the  sjTnphysis  pubis  with  the  patient  flat  on  her  back,  and  divided 
this  distance  by  the  smallest  circumference  of  the  abdomen,  and  to  avoid  frac- 
tions, multiplied  the  result  by  one  hundred.  The  index  thus  obtained  usually 
varied  betveen  sixty-five  and  ninety-five,  and  in  practically  every  case  in  which 
there  was  marked  nephroptosis,  the  index  was  high,  that  is,  above  seventy-five. 

Becker  and  Lennhoff  also  examined  many  South  Sea  Islanders,  with  whom 
the  customs  of  civilization,  as  clothing,  tight  lacing,  etc.,  could 
be  eliminated,  and  found  that  movable  kidney  was  just  about  as  frequent  as  in 
civilized  races. 

Deletzine  and  Volkoff  ascribe  the  more  frequent  occurrence  of  movable  kid- 
ney in  women  than  in  men  to  the  difference  in  the  renal  fossae  of  the 
two  sexes.  They  showed  that  in  men  the  fossee  in  which  the  kidneys  lie  are 
fairly  deep  and  wider  above  than  below,  that  is,  funnel-shaped ;  while  in  women 
they  are  more  cylindrical  and  wider  below,  especially  on  the  right  side. 

Pregnancy  has  been  given  the  most  conspicuous  place  as  an  etiological 
factor  by  some  persons,  and  its  advocates  maintain  that  it  acts  by  the  contrac- 
tion of  the  diaphragm  during  labor;  the  lessening  of  the  intra-abdominal  pres- 
sure after  the  expulsion  of  the  uterine  contents ;  and  finally,  the  loss  of  tone  of 
the  abdominal  muscles  with  a  resultant  flaccid  and  pendulous  condition  which 
also  tends  to  lessen  the  intra-abdominal  pressure  and  thus  favor  a  prolapse  of 
the  kidney. 

Gynecological  conditions,  such  as  malpositions  of  the  uterus  and  pel- 
vic timiors,  may  possibly  by  their  traction  upon  the  ureters  have  a  slight  tend- 
ency to  displace  the  kidneys.  Trauma,  either  single  or  repeated;  certain 
occupations  requiring  heavy  lifting;  and  also  prolonged  constipa- 
tion necessitating  severe  straining,  may  in  some  instances  assist  in  displacing 
the  kidneys. 

Harris  {Jour.  Amer.  Med.  Assoc,  June  1,  1901)  probably  came  nearer  the 
truth  than  any  other  writer  when  he  said :  "  The  fallacy  of  supposing  that  preg- 
nancy, lacerations  of  the  perineum,  displacements  of  the  uterus,  etc.,  are  in- 
strumental in  causing  movable  kidneys,  is  unanswerably  shown  by  the  fact  that 
over  forty  per  cent  of  the  cases  of  movable  kidneys  were  found  in  unmarried 
women,  in  women  who  have  thus  never  been  pregnant,  who  have  intact  perineal 
floors,  and  whose  uteri  are  in  normal  position.  That  these  factors  may,  and 
perhaps  at  times  do,  aggTavate  the  condition  caused  by  other  influences  is  ad- 
mitted." 

We  may  conclude  by  saying  that  it  is  becoming  more  and  more  probable 
that  there  is  no  single  cause  of  movable  kidney,  but  rather  a  combination  of 
influences  working  together. 

Frequency. — It  is  a  well  known  fact  that  movable  kidney  is  much  more 
frequent  in  women  than  in  men.  Statistics  vary  gi-eatly  as  to  the  relative 
frequency  in  the  two  sexes,  but  it  is  probably  ten  times  more  common  in  women. 
The  disposition  of  the  pelvic  organs  in  women,  together  with  the  effects  of 
labor,  are  probably  of  some  etiological  importance,  but  it  will  most  likely  be 


METHOD    OF    PALPATION.  609 

proven  that  the  differences  in  the  body  shape  in  the  two  sexes  is  also  of  great 
consequence. 

Observers  vary  greatly  in  their  opinions  as  to  the  relative  frequency  of  mov- 
able kidney  in  women,  due  in  part  to  the  fact  that  each  has  a  separate  standard 
by  which  he  decides  whether  a  kidney  is  abnormally  movable.  From  statistics 
taken  upon  white  women  in  the  Gynecological  Dispensary  of  the  Johns  Hopkins 
Hospital,  I  feel  safe  in  saying  that  at  least  twenty  per  cent  have  a  movable 
kidney.  In  most  of  the  cases  it  is  the  right  kidney  which  is  in  descensus, 
while  in  a  small  per  cent  the  nephroptosis  is  bilateral,  and  in  a  still  smaller 
per  cent  the  left  kidney  alone  is  movable. 

JSTephroptosis  may  occur  in  children,  indeed  there  are  many  cases 
on  record,  but  it  is  rare  compared  to  its  frequency  in  adults. 

Palpation  of  Kidney. — There  are  numerous  methods  and  positions 
for  palpating  a  movable  kidney,  each  of  which  has  its  advantages  and  disad- 
vantages, but  the  necessary  prerequisite  for  a  thorough  palpation  of  any  kidney 
is  a  complete  relaxation  of  the  abdominal  muscles. 

Some  surgeons  in  palpating  prefer  to  use  only  one  hand ;  for  example,  in 
examining  the  right  kidney  they  use  the  left  hand,  placing  the  fingers  in  the 
loin  below  the  twelfth  rib  and  external  to  the  erector  spinse  muscles,  with  the 
thumb  on  the  abdomen,  and  attempting  to  palpate  the  kidney  by  bringing  fingers 
and  thumb  together.  I  prefer  the  bimanual  palpation,  however,  which  is  per- 
formed as  follows:  In  palpating  for  the  right  kidney  the  left  hand  is  placed 
in  the  loin  below  the  twelfth  rib  and  just  outside  the  erector  spinse  muscles,  and 
the  right  hand  is  placed  over  the  abdomen  just  below  the  costal  margin  external 
to  the  rectus  muscle.  The  patient  is  then  instructed  to  take  a  fairly  deep  breath, 
and  during  expiration  the  hands  are  brought  together.  As  mentioned  above, 
the  whole  secret  lies  in  securing  a  thorough  relaxation  of  the  abdominal  mus- 
cles, and  to  obtain  this  the  position  of  the  patient  is  most  important.  She  may 
be  on  her  back  in  a  reclining  position,  about  midway  between  the  sitting 
posture  and  complete  dorsal  decubitus,  and  with  the  thighs  slightly  flexed.  This 
usually  gives  a  good  relaxation,  there  is  some  tendency  for  the  kidneys  to 
descend  by  gravity,  and  either  side  may  be  examined  without  changing  the 
position  of  the  patient.  Another  excellent  position  is  to  have  the  patient  stand, 
and  in  order  to  examine,  for  instance,  the  right  kidney,  have  her  lean  forward 
and  a  little  to  the  right,  with  the  right  foot  placed  on  some  object  about  six 
inches  high.  This  will  secure  good  relaxation  and  give  gravity  full  play. 
Another  method  is  to  place  the  patient  in  the  left  lateral  or  Sims'  position  to 
examine  the  right  kidney,  and  in  the  right  lateral  position  to  examine  the  left 
kidney. 

It  sometimes  happens  that  a  movable  kidney  can  be  distinctly  felt  at  one 
examination,  but  cannot  be  made  out  subsequently,  owing  to  the  fact  that  it 
has  slipped  up  under  the  ribs  and  is  temporarily  held  in  that  position.  Fre- 
quently, however,  if  the  patient  will  walk  briskly  about  or  make  some  exer- 
tion, the  kidney  will  fall  down  into  its  abnormal  position  and  be  easily  felt. 
40 


610  MOVABLE    KIDNEY. 

In  some  cases  it  is  helpful  to  try  the  bimanual  vibratory  palpation  as  de- 
scribed in  the  Journal  of  the  American  Medical  Association,  June  1,  1907. 
■This  method  is  performed  as  follows :  With  one  hand  placed  below  the  lower 
pole  of  the  kidney,  or  tumor,  as  the  case  may  be,  the  other  hand  makes  light 
taps  over  the  mass  at  the  rate  of  about  three  to  five  a  second,  and  with  an  ampli- 
tude not  exceeding  one  centimetre.  As  long  as  the  palpation  is  made  over  the 
mass  the  vibratory  waves  are  transmitted  to  the  under  hand,  but  just  as  soon 
as  the  outer  limits  are  passed,  these  impulses  can  no  longer  be  felt,  and  thus 
any  object  can  be  more  accurately  outlined  than  by  the  ordinary  methods  of 
palpation. 

Symptoms. — Probably  no  other  pathological  condition  in  the  abdomen  pre- 
sents such  varied  and  often  vague  symptoms  as  movable  kidney.  The  symptoms 
in  a  great  many  cases  are  so  far  distinct  from,  and  have  apparently  so  little 
connection  with  the  kidney,  that  they  are  frequently  attributed  to  some  other 
organ.  A  large  proportion  of  the  movable  and  also  of  the  floating  kid- 
neys do  not  cause  symptoms,  l^early  every  practitioner  of  much  experi- 
ence can  recall  cases  in  which  the  kidney  had  "  run  wild  "  and  could  be  dis- 
placed to  the  iliac  fossa  or  even  to  the  opposite  side  of  the  abdomen,  but  which 
had  caused  absolutely  no  discomfort.  While  on  the  other  hand,  a  comparatively 
slight  abnormal  mobility  has  caused  violent  manifestations  of  pain,  nausea, 
vomiting,  etc.,  which  have  been  completely  relieved  by  proper  treatment 
of  the  kidney.  Whenever,  therefore,  in  the  routine  examination  of  our 
patient  we  accidentally  discover  a  prolapsed  kidney  of  which  the  patient 
is  ignorant,  and  which  has  given  her  no  trouble,  it  is  best  to  let  well  enough 
alone  and  avoid  interference;  it  is  of  great  importance  that  the  patient 
should  be  kept  in  blissful  ignorance  of  her  condition,  for  it  frequently  hap- 
pens that  the  very  knowledge  of  the  fact  that  the  kidney  is  out  of  place 
will  induce  a  long  train  of  the  mental  and  nervous  disorders  known  as 
neurasthenia. 

Pain. — The  cardinal  symptom  of  movable  kidney  is  pain,  which,  how- 
ever, varies  greatly  both  in  character  and  intensity  in  different  cases,  and  even 
in  the  same  person  at  different  times.  The  pain  commonly  associated  with 
movable  kidney,  however,  is  a  dragging  or  aching  sensation,  which  may  be  so 
mild  that  the  patient  is  barely  conscious  of  its  existence,  or,  in  many  cases, 
is  so  severe  that  she  cannot  keep  about  at  all,  and  is  only  partially  relieved  by 
lying  down.  The  attacks  of  intense  pain,  called  "  Dietl's  crises,"  are  present 
only  in  exceptional  cases. 

Dietl  (Wien.  med.  Wochensch.,  1864)  considered  these  "crises"  to  be 
the  result  of  a  temporary  kink  or  twist  of  the  renal  vessels  and  a  consequent 
strangulation;  comparable  in  character  to  the  strangulation  of  a  hernia.  The 
explanation  now  generally  accepted  and  advocated  especially  by  Osier  is  that 
the  paroxysms  are  due  to  a  kink  in  the  upper  part  of  the  ureter,  causing  a 
damming  back  of  urine  into  the  pelvis  and  calicos,  and  thus  a  transient 
hydronephrosis.       The  artificial  reproduction  of  the  exact  symptoms  of  a 


SYMPTOMS.  611 

Dietl's  crisis  by  the  distention  of  the  kidney  with  sterile  water,  which  will  be 
described  later,  certainly  seems  to  substantiate  this  view. 

An  attack  of  sharp  pain  may  excite  the  first  suspicion,  either  to  patient  or 
physician,  of  an  abnormally  movable  kidney,  for  although  there  may  have  been 
previously  slight  aches  and  pains,  they  are  usually  ascribed,  without  an  exam- 
ination, to  a  "  touch  of  indigestion,"  lumbago,  or  neuralgia,  until  acute  sjnnp- 
toms  necessitating  a  thorough  investigation  clear  up  the  diagnosis.  These 
paroxysms  usually  come  on  rather  suddenly,  often  following  severe  exercise, 
jolting,  or  even  an  indiscretion  in  diet.  The  patient  is  seized  with  a  sharp 
agonizing  pain  in  the  region  of  one  of  the  kidneys,  accompanied  by  a  feeling 
of  nausea  and  faintness.  The  pain  is  most  frequently  confined  to  the  region 
of  the  kidney,  but  it  sometimes  radiates  downward  along  the  course  of  the 
ureter,  or  across  to  the  other  side  of  the  abdomen,  or  upward  even  to  the 
shoulder-blade.  If  seen  within  the  first  hour  or  so  after  the  onset,  a  correct 
diagnosis  can  usually  be  made,  for  on  examination  the  physician  discovers 
slight  enlargement  of  the  kidney,  which  upon  palpation  causes  an  accentua- 
tion of  the  symptoms  of  nausea,  faintness,  or  even  partial  collapse,  from  which 
the  patient  is  already  suffering.  In  the  most  severe  cases,  after  several  hours 
there  may  be  marked  abdominal  distention  and  tenderness,  and  the  patient 
becomes  bathed  in  a  cold  sweat,  so  that  the  condition  could  be  easily  mistaken 
for  one  of  intestinal  perforation  or  even  of  peritonitis.  Sometimes  the  symp- 
toms continue  severe  for  several  days,  but,  as  a  rule,  within  twenty-four  hours 
the  pain  and  tenderness  subside  and  the  patient  makes  a  rapid  recovery. 

There  may  be  a  noticeable  decrease  in  the  amount  of  urine,  with 
albumen,  casts,  or  even  blood  voided  during  an  acute  attack,  followed 
by  a  compensatory  increase  of  pale  urine  with  low  specific  gravity  during  the 
subsidence  of  the  symptoms. 

A  marked  temporary  hydronephrosis,  occuring  in  a  Dietl's  crisis,  affords 
a  typical  example  of  the  so-called  "  phantom-tumor,"  for  on  examination  a 
large  mass  can  be  outlined  in  the  flank,  which  a  day  or  so  later  has  completely 
disappeared. 

Between  the  Dietl's  crises  the  health  of  the  patient  is  most  commonly 
excellent,  except  for  occasional  slight  dragging  pains  and  some  discomfort,  but 
she  is  kept  in  a  constant  state  of  anxiety,  knowing  that  the  slightest  error  in 
exercise  or  diet  may  precipitate  another  attack. 

The  great  danger  to  be  feared  in  these  cases  of  temporary  or  intermittent 
hydronephrosis  is  that  they  will  become  changed  into  a  permanent 
hydronephrosis   or  even  pyonephrosis. 

Gastro-intestinal. — Although  gastric  symptoms  are  not  common  mani- 
festations of  movable  kidney,  yet  symptoms  referable  to  the  stomach,  in- 
testine,  appendix,   or  gall  bladder  are  occasionally  seen. 

As  a  rule,  the  symptoms  are  mild  in  character  and  amount  only  to  slight 
flatulence,  dyspepsia,  or  constipation,  but  they  may  be  so  severe  as 
to  simulate    acute    gastritis,    gastric    ulcer,    appendicitis,    or    gall 


612  .  MOVABLE    KIDNEY. 

stones.  Moullin  (Lancet,  Decemlier  10,  190-i)  rcijorted  an  interesting  ease  in 
which  the  symptoms  resembled  those  of  gastric  ulcer:  ''  The  patient  was  a 
married  woman,  forty-four  years  of  age,  who  had  had  nine  children,  six  of 
whom  were  living.  For  the  last  twenty  years  she  had  suffered  from  pain  in 
the  epigastrium,  shooting  around  to  the  back  and  shoulders.  The  pain  invari- 
ably came  on  from  a  quarter  to  half  an  hour  after  meals.  Solid  food  made  it 
worse,  vomiting  was  frequent,  and  was  rather  encouraged  as  it  relieved  the  pain. 
Scarcely  a  day  passed  without  at  least  one  attack,  and  for  the  past  nine  months 
there  had  been  no  respite.  Twenty-one  months  ago  there  had  been  three  attacks 
of  hematemesis,  the  amount  said  to  have  been  as  much  as  three  quarts,  and 
there  was  melena  at  the  same  time.  The  abdomen  was  large  and  flabby.  Ac- 
cording to  the  patient's  account  she  had  been  getting  thinner.  The  stomach 
was  not  dilated  nor  displaced,  the  lower  border  being  situated  about  two  inches 
above  the  umbilicus.  There  was  a  little  tenderness  on  deep  pressure  to  the 
right  of  the  epigastrium,  but  no  tumor  could  be  felt.  Both  kidneys  were  mov- 
able, the  right  one  in  particular  descending  so  far  when  the  patient  strained  or 
coughed  that  it  came  quite  below  the  thorax  and  the  hands  could  be  made  to 
meet  above  it.  While  in  the  ward  lying  in  bed  waiting  for  operation,  the 
vomiting,  which  had  been  more  and  more  troublesome  and  which  was  the  im- 
mediate cause  of  her  seeking  admission,  ceased  entirely,  and  the  pain  after  food 
diminished  so  materially  that  it  scarcely  interfered  with  her  comfort.  This  led 
to  the  conclusion  that  the  mobility  of  the  right  kidney  was  the  chief,  if  not  the 
sole,  cause  of  her  symptoms,  whether  it  acted  mechanically  by  dragging  upon 
the  duodenum  and  pylorus,  or  whether  it  irritated  the  splanchnics  in  some  way, 
leading  to  persistent  congestion  of  the  mucous  membrane  of  the  stomach  with 
its  attendant  consequences,  chronic  gastritis  and  hematemesis."  In  this  case  the 
kidney  was  suspended  with  complete  relief  of  the  severe  pain  and  vomiting. 

The  ease  with  which  nephroptosis  may  simulate  appendicitis  is  well  shown 
by  a  case  which  was  operated  upon  at  the  Johns  Hopkins  Hospital  about  four 
years  ago  (Gyn.  'No.  1097Y).  The  patient,  a  colored. woman,  age  twenty-four, 
had  had  neither  children  nor  miscarriages.  She  had  always  suffered  from 
dysmenorrhea  and  irregular  menstruation.  Until  December  18,  1903  (about 
three  weeks  before  her  operation),  she  had  not  menstruated  for  six  months,  but 
she  had  suffered  practically  no  pain.  On  the  above  date  the  menstrual  flow 
began  and  lasted  two  to  three  days,  accompanied  by  pain  in  the  right  side  of 
abdomen,  which  persisted  off  and  on,  growing  more  and  more  severe  and  cramp- 
like in  character.  The  attacks  of  pain  were  accompanied  by  nausea,  vomiting, 
and  obstinate  constipation,  and  the  patient  was  confined  to  bed  for  two  to  three 
days  during  each  attack.  She  said  that  during  the  acute  symptoms  she  had  no 
desire  to  urinate,  and  frequently  did  not  void  her  urine  for  two  or  three  days, 
and  when  she  did  there  would  be  only  a  small  amount  which  caused  some  smart- 
ing and  burning.  Owing  to  the  rigid  condition  of  the  abdomen,  the  physical 
examination  was  very  unsatisfactory,  and  although  the  right  kidney  was  found 
movable,  it  was  not  suspected  as  the  seat  of  the  trouble.     A  diagnosis  of  ap- 


DIFFERENTIAL    DIAGNOSIS.  gl3 

pendicitis  having  been  made,  a  laparotomy  was  done  and  a  normal  appendix 
removed.  As  the  symptoms  continued  and  the  operation  did  not  reveal  any 
cause,  the  kidney  was  suspected.  Sterile  water  colored  with  methylene  blue  was 
injected  into  the  right  kidney,  which  reproduced  the  exact  symptoms  of  which 
the  patient  complained,  proving  conclusively  the  renal  origin. 

Biliary. — Attacks  of  colic  in  the  right  side  accompanied  by  nau- 
sea and  vomiting  as  well  as  intense  jaundice  seem  characteristic  of 
gall-stones,  but  all  of  these  symptoms  may  be  caused  by  a  movable  kidney. 
I  recently  had  such  a  case  in  which  I  made  a  diagnosis  of  gall-stones  and 
then  did  an  exploratory  laparotomy  which  disclosed  a  normal  gall-bladder 
and  gall-ducts,  but  showed  the  right  kidney  pressed  against  the  common  bile- 
duct.  I  closed  the  abdominal  incision,  put  the  patient  upon  a  kidney-bag, 
and  suspended  the  kidney.  She  recovered  promptly  from  the  operation  and 
has  now  been  perfectly  well  for  about  two  years. 

ISTervous. — Although  the  nervous  manifestations  of  a  movable  kid- 
ney are  vague  and  indefinite,  they  are  none  the  less  real.  Headaches 
and  vertigo  are  common.  A  bright  and  cheerful  person  may  become  fretful 
and  irritable,  and  in  extreme  cases  even  approach  hypochondriasis. 

Circulatory. — Venous  congestion  and  edema  of  the  leg  have 
been  reported  as  occurring  in  association  with  movable  kidney,  but  it  must 
have  been  an  exceptional  case.  1  have  never  seen  one  of  the  kind  myself. 
It  is  worth  noting,  however,  that  Rayer  attributed  a  swelling  of  the  leg 
which  he  found  at  an  autopsy  to  a  movable  kidney  present  upon  the  same 
side. 

Urinary. — Except  for  the  changes  in  the  amount  of  urine  occur- 
ring in  a  Dietl's  crisis,  the  urinary  manifestations  are  not  very  charac- 
teristic. There  might  be  a  little  albumen  or  a  few  casts,  but  these  occur  in 
so  many  conditions  that  it  is  difficult  to  say  whether  it  is  the  result  of  or 
merely  coincident  with  the  nephroptosis.  Occasionally,  a  little  blood  is  seen 
in  the  urine  by  the  aid  of  the  microscope,  an4  a  few  years  ago  Cabot,  of  Boston, 
reported  a  case  of  severe  hematuria  with  anemia  and  weakness,  resulting  from 
a  movable  kidney,  all  of  which  were  relieved  by  nephropexy.  The  occurrence 
of  hematuria,  however,  would  indicate  that  some  other  change  in  the  kidney 
was  associated  with  the  movability,  and  we  know  that  bleeding  kidneys  which 
are  not  movable  have  been  cured  by  nephropexy. 

Differential  Diagnosis. — The  great  majority  of  the  cases  of  movable  kidney 
with  or  without  symptoms  can  and  should  be  correctly  diagnosed  by  any  prac- 
ticing physician;  but  on  the  other  hand,  there  are  a  certain  number  of  cases 
which  puzzle  even  the  best  of  clinicians.  As  I  have  said  before,  we  should 
always  hesitate  a  long  time  before  ascribing  any  symptoms  to  a  movable  kid- 
ney unless  the  kidney  can  be  felt,  and  even  then  we  should  try  to  eliminate 
pathological  conditions  of  any  other  abdominal  organ.  After  a  positive  diag- 
nosis has  been  made,  the  physician  will  be  perplexed  over  and  over  again  to 
know  just  how  much  of  the  symptoms  of  which  the  patient  complains  should 


614  MOVABLE    KIDNEY. 

be  attributed  to  the  faulty  position  of  the  kidney  and  just  how  much  to  a 
neurotic  element. 

I  will  mention  briefly  some  of  the  conditions  with  which  movable  kidney  is 
most  likely  to  be  confused,  and  give  a  few  points  of  differential  diagnosis. 

Distended  Gall  Bladder. — A  very  movable  right  kidney  may  descend 
to  the  left  so  far  as  to  protrude  as  a  rounded  organ  beneath  the  margin  of  the 
liver  and  be  confused  with  the  gall  bladder.  By  manipulating  the  kidney  or 
by  turning  the  patient  on  her  right  side,  it  may  be  forced  back  into  its  normal 
position.  In  these  cases  there  is  usually  a  sufficient  absence  of  previous  history 
to  suggest  involvement  of  the  gall  ducts,  and  the  jaundice  which  may  occur  is. 
said  to  be  not  so  intense  as  that  caused  by  a  tumor  of  the  gall  bladder. 

Although  both  the  kidney  and  gall  bladder  move  with  respiration,  the  for- 
mer can  be  grasped  and  held  down  during  expiration,  while  the  latter  cannot. 
The  gall  bladder  can  be  moved  to  the  right  or  to  the  left  but  not  downward, 
while  a  freely  movable  or  floating  kidney  can  be  displaced  in  almost  any  direc- 
tion. Also  the  edge  of  the  liver  can  usually  be  felt  separate  and  distinct  from 
the  movable  kidney,  whereas,  between  the  gall  bladder  and  liver  there  is  no 
sharp  and  definite  demarcation.  The  position  of  the  colon,  especially  when  dis- 
tended, may  in  some  cases  be  helpful  in  differentiating  the  two  conditions. 

A  movable  kidney  when  displaced  has  a  tendency  to  slip  back  into  its 
position  in  the  loin,  whereas  a  gall  bladder,  although  it  may  be  pushed 
back  into  the  loin,  will  tend  to  spring  forward  to  the  anterior  portion  of  the 
abdomen. 

It  must  be  borne  in  mind  that  a  movable  kidney  and  a  distended  gall 
bladder  frequently  occur  in  the  same  person,  and  each  may  cause  symptoms. 

Tumors  Arising  from  the  Pelvis. — That  a  floating  kidney  may  be 
confused  with  timiors  arising  from  the  pelvis  is  well  shown  by  a  case  operated 
upon  at  the  Johns  Hopkins  Hospital.  A  white  woman,  age  forty-six  (Gyn. 
Xo.  10286),  mother  of  six  children,  entered  the  hospital  in  February,  1903, 
with  the  following  history:  In  September,  1901,  she  noticed  considerable  sore- 
ness in  both  groins,  and  while  palpating  her  abdomen  observed  a  lump  in  her 
right  side  which  she  could  move  about  almost  anywhere  in  the  abdomen.  In 
February,  1902,  she  consulted  a  physician,  who  examined  her  and  told  her  she 
had  an  ovarian  tumor.  Since  then  she  had  had  considerable  discomfort  on  the 
right  side,  mostly  a  dull,  throbbing,  aching  pain,  which  was  usually  confined  in 
the  right  groin,  but  which  at  times  ran  upward  under  the  "  small  ribs."  The 
pain  was  worse  at  night  and  patient  rested  best  on  her  left  side.  She  had  had 
backache  ever  since  she  had  borne  children.  Her  appetite  was  good,  her  bowels 
regTilar,  and  micturition  normal.  After  a  thorough  examination,  including  a 
distention  of  the  kidney  with  sterile  water  and  reproduction  of 
the  exact  pain,  a  diagnosis  of  movable  kidney  was  made,  and  nephrorrhaphy 
done,  with  a  complete  relief  of  symptoms. 

Before  venturing  a  diagnosis  in  doubtful  cases  between  movable  kidney 
and  a    tumor    of    pelvic    origin,    a  vaginal  or  rectal  examination  should 


DIFFEKENTIAL    DIAGNOSIS.  615 

always  be  made,  for  in  many  cases  a  distinct  pedicle  can  be  felt  connecting  the 
tumor  with  the  pelvis,  which  instantly  clinches  the  diagnosis. 

The  order  of  frequency  of  the  various  tumors  arising  from  the  pelvis  which 
are  confused  with  the  kidney  is,  probably,  ovarian  cysts  (usually  dermoid)  ; 
pedunculate,  subserous,  uterine  myomata ;  and  occasionally  paro- 
varian cysts.  ISTaturally,  these  tumors  would  have  to  be  fairly  small  and 
with  a  long  pedicle. 

The  points  to  be  emphasized  in  differentiating  these  tumors  from  movable 
kidney  are: 

(1)  A  careful  history  of  the  onset  and  duration. 

(2)  Impossibility  of  displacement  upward  behind  the  ribs  into  the  loin. 

(3)  Possibility  of  feeling  tumor  on  vaginal  or  rectal  examination. 

(4)  Possibility  of  distinguishing  a  pedicle,  on  vaginal  or  rectal  examina- 
tion, felt  to  connect  the  tumor  with  the  pelvis. 

(5)  Movement  in  the  arc  of  a  circle,  whose  centre  is  in  the  pelvis. 

(6)  A  gradual  increase  in  size  demonstrated  by  careful  observation. 
Tumors  of  the  Pylorus. — A  case  reported  by  Osier  ("Lectures  on  the 

Diagnosis  of  Abdominal  Tumors  "),  in  which  he  mistook  a  tumor  of  the  pylorus 
for  a  floating  kidney,  illustrates  the  similarity  which  may  occur  between  the  two 
conditions. 

His  case  was  a  colored  woman,  aged  fifty-six  years,  who  entered  the  hos- 
pital complaining  of  pain  in  the  abdomen  and  vomiting.  She  had  been  married 
twelve  years  and  had  had  six  children  and  four  miscarriages.  She  was  always 
healthy  until  the  onset  of  her  present  symptoms,  which  were  entirely  of  a 
gastro-intestinal  nature,  about  four  months  before  her  admission. 

The  physical  examination  was  as  follows :  "  The  walls  are  very  loose,  flabby, 
and  thrown  into  many  folds.  In  the  right  hypochondriac  and  right  epigastric 
regions  there  is  a  marked  rounded  prominence,  which  extends  below  to  within 
two  centimetres  of  navel  and  reaches  nearly  to  middle  line.  It  descends  slightly 
with  inspiration.  On  palpation  this  proves  to  be  a  solid  mass,  which  can  be 
grasped  and  is  freely  movable.  It  is  irregular,  rounded,  not  reniform,  but  is 
smooth  at  its  upper  and  right  borders,  more  irregular  below  and  to  the  left, 
but  a  definite  hilum  is  not  to  be  felt.  To  the  touch  there  is  conveyed  a  sense  of 
firm  yet  elastic  resistance,  such  as  is  given  by  a  solid  organ.  On  prolonged 
palpation  no  gas  is  felt  passing  through  it.  It  is  extraordinarily  mobile  and 
can  be  pushed  into  the  epigastric  region  far  over  into  the  right  hypochondriac 
region,  and  below  into  the  right  lumbar  and  iliac  regions  to  a  level  with  the  line 
of  the  anterior  superior  spines.  On  firm  pressure  the  liver  margin  can  even  be 
forced  into  the  iliac  region.  It  can  also  be  pushed  into  the  right  hypochondriac 
region,  so  as  to  be  covered  almost  completely  by  the  ribs,  and  in  subsequent 
examinations  this  was  not  infrequently  the  situation  in  which  it  was  found, 
and  from  which  it  could  be  dislocated  only  by  the  deepest  inspiration  or  by  deep 
pressure  in  the  renal  region.  The  mass  is  not  tender  even  on  firm  pressure. 
There  is  dulness  over  it,  but  not  complete  flatness.     The  patient  notices  that 


616 


MOVABLE    KIDNEY. 


the  mass  changes  in  position  as  she  moves  about,  and  when  she  sits  up  it  moves 
far  down  into  the  abdomen,  while  when  on  her  back  it  is  frequently  beneath 
ihe  right  ribs.  When  this  mass  is  out  from  beneath  the  right  costal  margin  the 
right  kidney  cannot  be  felt,  nor  on  the  left  side  on  the  deepest  inspiration, 
could  the  kidney  be  palpated.  Beyond  these  are  depressions  in  the  renal  regions. 
The  edge  of  the  liver  cannot  be  felt;  the  area  of  splenic  dulness  is  not  in- 
creased ;  the  edge  cannot  be  reached  even  on  deep  inspiration." 

In  discussing  the  case,  Dr.  Osier  mentioned  the  possibility  of  a  pyloric 
tumor,  but  concluded  by  saying:  "  Here  the  mass  is  of  unusual  mobility  and 
can  be  passed  into  the  renal  region  on  the  right  side.  It  has  not  a  reniform 
shape,  but  it  has  the  consistence  and  resistance  of  the  kidney.  A  point  very 
much  in  favor  of  its  renal  character  is  the  mobility  dovTiward,  and  a  tumor  of 
this  sort,  which  can  be  pushed  up  beneath  the  ribs  and  also  far  down  to  the 
iliac  regions,  is  certainly  highly  suggestive  of  floating  kidney.  Another  impor- 
tant fact  is  that,  in  a  woman  with  such  a  lax  abdominal  wall,  no  right  kidney 
can  be  felt.  The  gastric  disturbance  and  dilatation  of  the  stomach  present  are 
both  explicable  on  the  view  that  this  tumor  mass  has  compressed  the  duodenum 
and  caused  a  secondary  dilatation.  Xor  is  this,  considering  the  history  of  so 
many  cases,  inconsistent  with  the  view  that  the  tumor  mass  may  be  really  a 
kidney.  On  the  other  hand,  the  tumor  has  not  the  shape  of  a  kidney  and  a 
distinct  hilum  cannot  be  felt.  Xo  left  kidney  can  be  palpated,  and  it  may  be 
that  this  is  an  instance  of  conglomerate  kidney,  such  as  was  found  in  Polk's 
celebrated  case." 

An  exploratory  laparotomy  showed  the  tumor  to  be  a  solid  growth  of 
the  anterior  wall  and  lesser  curvature  of  the  stomach  in  the 
pelvic   region. 

It  is  very  rare  that  a  case  as  confusing  as  this  one  is  encountered,  for  if  a 
careful  history  is  taken-with  especial  reference  to  the  duration  of  symptoms  and 
loss  of  weight  and  strength,  and  a  thorough  j^hysical  examination  is  made,  com- 
bined with  a  microscopical  and  chemical  examination  of  the  gastric  contents,  a 
diagnosis  is  usually  not  difficult. 

Nephrolithiasis. — Stone  in  the  kidney  or  nephrolithiasis  may 
give  symptoms  which  closely  resemble  those  occurring  with  a  movable  kidney, 
and  vice  versa.  For  a  differentiation,  a  careful  microscopical  examination- of 
the  urine,  together  with  its  reaction,  is  important,  and  it  is  especially  helpful 
to  contrast  the  urines  obtained  by  catheterization  of  each  ureter.  The  urine 
obtained  from  catheterization  of  the  ureter  on  the  suspected  side  should  be 
examined  for  small  fragments  of  calculus  which  may  be  brought  do^vn. 

The  X-ray  is  naturally  a  valuable  aid  in  differential  diagnosis,  but  it  cannot 
always  be  relied  upon,  for  the  stone  may  be  so  soft  or  else  so  located  that  it  is 
not  shown  on  the  radiograph. 

A  more  valuable  means  of  diagnosis  is  the  wax-tip  catheter,  which  is  made 
by  immersing  the  end  of  an  ordinary  ureteral  catheter  in  a  mixture  of  dentist's 
wax  and  olive  oil.     This  is  then  passed  up  into  the  kidney,  withdrawn,  and 


DIFFERENTIAL    DIAGNOSIS. 


617 


examined  with  a  hand-lens,  when,  if  a  stone  is  present,  little  gouges  or  excava- 
tions can  be  seen  in  the  wax,  whereas  a  normal  pelvis  or  ureter  will  leave  the 
tip  unaltered  (see  Fig.  27,  p.  29). 

Eecal  Accumulations. — The  beginner,  in  palpating  for  a  movable  kid- 
ney, may  sometimes  be  confused  by  the  accumulations  in  the  colon,  but  after  a 
little  practice  the  soft  boggy  feel  of  the  feces  becomes  almost  pathognomonic. 

Probably  the  best  single  means  at  our  disposal  of  differentiating  pathological 
conditions  of  the  kidney,  especially  movable  kidney,  from  affections  not  of  renal 
origin  is  the  artificial  reproduction  of  renal  colic.  For  those  who 
may  be  interested,  this  method  is  published  by  Kelly  (loc.  cit.)  and  H.  T. 
Hutchins  (Amer.  Jour.  Ohst.,  1906,  vol.  54,  p.  331),  and  will  be  described 
here  only  briefly. 

After  a  thorough  history  relative  to  any  previous  kidney  or  bladder  trouble 
is  obtained,  the  patient  is  told  that  the  bladder  will  be  examined,  and  nothing 
is  said  of  the  kidney.  With  the  patient  in  the  knee-breast  position,  a  catheter 
just  large  enough  to  fill  the  ureter  is  passed  up  into  the  renal  pelvis ;  the  patient 
is  then  allowed  to  lie  on  her  side,  and  the  rate  of  flow  of  urine  from  that  kidney 
is  carefully  noted.  A  syringe  filled  with  sterile  water  colored  with  methylene 
blue  is  now  attached  to  the  catheter  and  the  fluid  is  slowly  forced  into  the  kid- 
ney, the  exact  amount  being  measured,  provision  having  been  previously  made 
to  collect  reflux,  should  any  occur.  As  soon  as  the  pelvis  is  moderately  dis- 
tended, there  will  naturally  be  some  pain,  and  almost  invariably  the  patient 
will,  without  any  questioning, 
volunteer  the  information  as  to 
the  character  of  the  pain,  whether 
it  is  the  same  pain  of  which  she 
has  previously  suffered  or  not. 
If  her  former  pains  are  not  re- 
produced, the  chances  are  that 
the  kidney  is  not  at  fault;  if 
they  are  reproduced,  there  is 
very  little  doubt  as  to  the  renal 
origin. 

It  is  a  good  plan  in  studying 
a  movable  kidney  to  make  an 
aniline  outline  according  to  the 
method  described  in  Chapter  I, 
p.  17,  and  then  to  transcribe  this 
to  a  gauze  record  as  shown  in 
Figure  161. 

Treatment. — As  in  other  pathological  conditions,  so  in  movable  kidney,  there 
are  numerous  treatments  which,  although  harmless  per  se,  are  yet  dangerous  in 
that  they  give  false  hope  and  consume  the  time  which  should  be  given  to  more 
effective  measures.     I  refer  to  such  as    electricity,    massage,    and    cold 


Fig.  161. —  Gauze  Record  of  Displacement  of  the 
Right  Kidney. 


618  MOVABLE    KIDNEY. 

showers,  which  theoretically  tone  up  the  weak  and  flaccid  abdominal  wall, 
increase  the  intra-abdominal  pressure,  and  give  a  better  support  to  the  viscera, 
but  which  practically  are  of  very  little  value. 

Palliative.-^ Among  the  palliative,  or  to  speak  more  correctly,  non- 
operative  forms  of  treatment  for  displaced  kidney  the  bandage  is,  perhaps, 
the  most  important.  In  many  cases  a  properly  fitting  bandage,  combined  with 
the  use  of  suitable  gymnastic  exercises,  not  only  affords  temporary  relief,  but 
effects  a  permanent  cure.  The  cases  suited  for  treatment  by  means  of  a  band- 
age are  numerous;  indeed,  the  only  class  in  which  it  is  contra-indicated  are 
those  in  which  hydronephrosis  has  begun,  and  these  can  be  readily  excluded 
by  catheterization  and  injection  of  the  kidney.  A  properly  fitting  bandage 
should  give  relief  as  soon  as  it  is  put  on.  There  is  no  fixed  period  of  time 
during  which  it  should  be  worn.  It  is  of  great  importance  that  gymnastic 
exercises  should  be  employed  in  connection  with  the  bandage,  in  order  to 
streng-then  the  abdominal  muscles.*  These  can  be  taken  in  the  morning  before 
the  bandage  is  put  on  or  in  the  evening  after  it  is  removed.  They  consist  of 
some  form  of  bending  movements  which  bring  the  abdominal  muscles  into 
action,  and  the  physician  should  prescribe  those  which  he  thinks  most  likely 
to  be  beneficial  in  each  case.  Many  patients  with  a  displaced  kidney  are  much 
emaciated,  and  in  such  cases  everything  should  be  done  to  increase  the  body 
weight.  Specific  directions  must  be  given  for  diet  and  the  kinds  of  food 
carefully  selected.  The  methods  of  eating  also  must  be  regiilated,  and  the 
directions  on  this  point  given  for  the  treatment  of  neurasthenia  will  be  found 
valuable  in  the  class  of  patients  now  under  discussion  (see  Chap.  XXIII). 
With  improvement  in  nutrition  and  an  increase  in  the  strength  of  the  abdom- 
inal muscles  a  displaced  kidney  may  become  &s.ed  in  its  normal  position,  and 
even  when  there  is  no  fixation,  anatomically  speaking,  all  the  symptoms  may 
be  relieved  and  the  relief  persist  even  after  the  bandage  is  disused.  It  must 
always  be  remembered,  however,  that  there  are  some  cases  in  which  it  is 
impossible  to  give  relief  by  means  of  a  bandage,  and  this  may  be  due  to  some 
anatomical  peculiarity  in  the  individual. 

The  bandage  itseK  should  be  snugly  fitting  and  made  of  an  elastic  mate- 
rial. Its  upper  border  ought  to  be  just  below  the  margin  of  the  ribs  and  its 
lower  at  the  iliac  crest.  The  entire  lower  part  of  the  abdomen  should  be 
covered.  Such  a  bandage  should  always  have  some  kind  of  attachment  by 
which  it  is  pulled  down.  Any  intelligent  instrument  maker  can  make  such 
a  bandage,  but  in  no  case  should  the  physician  allow  his  patient  to  definitely 
adopt  it  until  he  has  assured  himself  that  it  fits.  I  have  found  it  of  service 
in  cases  where  the  bandage  is  made  from  measurements  to  send  a  pattern,  cut 
from  the  patient.  The  principle  of  the  bandage  is  to  afford  support  to  the 
lower  abdomen ;  very  occasionally  additional  benefit  may  be  secured  by  placing 
an  extra  pad  inside  of  it  so  that  pressure  is  applied  just  where  the  kidney 
would  descend.  The  bandage  should  always  be  applied  while  the  patient  is 
lying  down.     It  may  seem  superfluous  to  say  that  before  applying  it  the  kid- 


TREATMENT.  619 

ney  should  be  replaced  in  its  proper  position  in  the  loin,  but,  as  a  matter  of 
fact,  patients  will  often  complain  that  they  have  not  been  relieved  by  a  band- 
age or  have  even  been  made  worse  by  it,  and  upon  examination  it  will  be  found 
that  the  kidney  is  in  the  iliac  fossa  or  in  the  opposite  side  of  the  abdomen 
with  the  tight  bandage  above  it !  In  no  case  should  a  bandage  be  applied  with- 
out first  excluding  all  kidney  disease  other  than  the  movable  kidney. 

In  case  tlie  symptoms  are  not  relieved  and  the  physician  has  assured  him- 
self that  there  is  no  fault  in  its  mode  of  application,  he  should  begin  to  think 
of  some  other  renal  condition  as  the  cause  of  the  trouble  and  consult  a  spe- 
cialist. It  must  always  be  remembered  that  certain  patients  are  so  much 
annoyed  by  a  bandage  that  they  do  not  improve  as  they  should. 

During  an  attack  of  renal  colic  the  patient  should  be  put  to  bed  and  kept 
flat  on  her  back  until  all  acute  symptoms  have  subsided.  Some  sedative,  as 
trional,  codein,  or  even  morphin,  is  indicated,  and  hot  fomentations  to  the  ab- 
domen prove  both  soothing  and  helpful.  If  the  gastro-intestinal  symptoms  are 
prominent,  a  limited  diet,  preferably  liquid,  is  advisable  for  a  few  days  after 
the  attack. 

Radical. —  (1)  ISTephrorrhaphy. — ''Stitching  up"  the  kidney 
gives  the  best  results  of  any  method  of  treating  nephroptosis  of  which  we  are 
acquainted.  It  is  difficult  to  lay  down  any  general  rule  to  determine  which 
cases  are  and  which  are  not  suitable  for  nephrorrhaphy,  for  each  case  must  be 
decided  to  a  great  extent  upon  its  own  merits.  We  may,  however,  divide  all 
cases  of  nephroptosis  into  three  great  groups  with  reference  to  nephrorrhaphy. 

(a)  Those  cases  in  which  nephrorrhaphy  is  contra-indicated. — 
Under  this  heading  we  include  all  cases  which  have  given  no  symptoms,  and 
especially  those  cases  of  which  the  patient  herself  is  ignorant;  also  those  cases 
of  unilateral  or  bilateral  nephroptosis  associated  with  marked  general  viscerop- 
tosis, and  in  which  the  symptoms  are  relieved  by  a  suitable  binder.  Even  if 
the  bandage  does  not  give  relief,  nephropexy  is  still  contra-indicated  unless  the 
symptoms  are  very  severe  and  can  be  shown  to  be  caused  by  the  kidney  and 
not  by  the  descensus  of  the  other  viscera. 

(6)  Those  in  which  nephrorrhaphy  may  or  may  not  be  done, 
according  to  influencing  factors. — This  group  comprises  the  largest 
number  of  cases  of  nephroptosis  with  symptoms.  What  would  in  some  cases 
be  ample  indication  for  an  operation  would  not  in  other  cases  be  sufficient  to 
justify  it.  Naturally,  we  would  not  hastily  advise  an  operation  in  a  woman 
of  the  better  class  who  leads  a  life  of  ease  and  who,  with  the  aid  of  a  binder, 
gets  along  fairly  comfortably ;  whereas,  the  same  pathological  conditions  found 
in  a  washerwoman  who  is  upon  her  feet  all  day  at  hard  work  and  to  whom 
health  is  absolutely  essential,  would  be  sufficient  indication  for  radical  treat- 
ment. We  must  also  be  duly  influenced  by  the  mental  and  nervous  condition 
of  the  patient,  for  naturally  we  can  hope  for  and  expect  better  results  in  per- 
sons who  are  intelligent  and  frank  about  their  symptoms,  than  in  those  who 
are  neurotic  and  prone  to  emphasize  every  little  ailment.     Probably  the  one 


620  MOVABLE    KIDNEY. 

most  important  symptom  which  should  guide  us  in  our  course  of  treatment  is 
pain,  and  we  should  hesitate  a  long  time  before  advising  operation  solely 
for  nervous  or  gastro-intestinal  disorders;  for  these  latter  symptoms  are  so  fre- 
quently associated  with  a  neurotic  temperament  that  unless  we  are  extremely 
careful  we  are  apt  to  bring  a  valuable  ojDeration  into  disrepute  b}^  applying 
it  to  unsuitable  cases. 

(c)  Cases  in  which  nephrorrhaphy  is  absolutely  indicated. — 
When  in  spite  of  a  quiet  life,  rest  in  the  recumbent  posture,  and  a 
carefully  applied  binder,  the  pain,  faintness,  and  other  acute 
symptoms  continue,  more  radical  treatment  is  absolutely  indi- 
cated, both  for  the  relief  of  symptoms  and  the  prevention  of  compli- 
cations. 

A  few  statistics  gathered  from  the  gynecological  records  of  the  Johns  Ho]3- 
kins  Hospital  will  convey  an  idea  of  the  frequency  of  nephrorrhaphy  at  this 
institution. 

In  the  first  thirteen  thousand  three  hundred  and  thirty-eight  gynecological 
patients  admitted,  the  right  kidney  was  suspended  one  hundred  and  twenty- 
seven  times.  It  was  suspended  alone  in  seventy-two  cases,  with  the  left  kidney 
in  ten  cases,  and  with  other  operations  in  forty-five  cases. 

The  left  kidney  was  suspended  thirty-eight  times,  in  twenty-eight  of  which 
there  was  no  other  operation,  while  in  the  other  ten  cases  the  right  kidney 
was  also  suspended. 

In  all  these  cases  only  one  was  in  the  colored  race  and  one  hundred  and 
fifty-five  in  the  whites.     There  were  no  deaths. 

Of  the  thirteen  thousand  three  hundred  and  thirty-eight  cases  admitted, 
approximately  eight  thousand  were  white  patients,  showing  that  of  all  white 
cases  admitted  to  the  gynecological  service,  less  than  two  per  cent  were  operated 
upon  for  movable  kidney. 

As  mentioned  previously,  statistics  carefully  taken  in  reference  to  movable 
kidney  among  gynecological  patients,  indicate  that  it  occurs  in  twenty  per 
cent  or  more  of  all  cases.  Thus  we  see  that  less  than  ten  per  cent  of  all  cases 
of  movable  kidney  in  white  women  are  operated  upon,  showing  how  foolish  it 
would  be  to  advise  radical  treatment,  simply  because  the  kidney  was  in  an 
abnormal  position. 

The  result  of  nephropexy,  when  done  in  suitable  cases,  is  excellent, 
being  successful  in  nearly  one  hundred  per  cent  of  cases.  The  failures  which 
occur  can  usually  be  attributed  either  to  too  hasty  operation  in  cases  which 
have  not  been  properly  differentiated,  or  to  the  fact  that  there  is  some  other 
pathological  condition  in  the  kidney  which  has  been  overlooked  and  to  which 
appropriate  treatment  should  also  have  been  given.  Sometimes  after  nephror- 
rhaphy there  is  a  slight  dragging  pain  which  was  not  present  before  operation, 
but  which  is  so  trifiing  compared  with  the  symptoms  relieved  by  operation, 
that  the  patient  considers  herself  cured. 

The    mortality    of   nephrorrhaphy    in  the  hands  of  the  best  surgeons 


TREATMENT.  621 

is  jDractieally  nil,  while  the  mortality  by  all  operators,  both  good  and  bad  taken 
together,  would  probably  be  less  than  three  per  cent. 

The  advantages  of  nephropexy  over  nephrectomy  are  numerous  and  self- 
evident.  It  would  be  poor  judgment,  to  say  the  least,  to  remove  an  organ 
when  a  conservative  operation  will  give  the  same  or  even  better  results,  with 
a  far  smaller  mortality. 

(2)  JN^ephrectomy. — As  m.entioned  above,  nephrectomy  should  never  be 
done  in  a  simple  uncomplicated  movable  kidney.  There  are,  however,  times 
when  nephrectomy  is  necessary  and  the  operation  of  choice,  but  then  the  indi- 
cation is  not  the  mobility  of  the  kidney  but  some  other  pathological  condition 
which  is  coincident  with  or  resultant  from  it,  such  as  tuberculosis,  stone,  or  a 
high  grade  of  hydronephrosis.  Also  it  is  sometimes  justifiable  in  cases  of 
floating  kidney  which  have  become  more  or  less  fixed  in  some  other  portion  of 
the  abdomen  and  cannot  be  replaced  in  the  loin. 

Before  removing  a  kidney  it  is  necessary  to  be  sure  that  the  other  kidney 
is  normal  and  capable  of  doing  compensatory  work. 


CHAPTEE    XXVI. 

POST-OPERATIVE   CONDITIONS. 

General  health,  p.  622.  Constipation,  p.  625.  Food,  p.  625.  Exercise,  p.  625.  Local  pain,  p. 
626.  Headache,  p.  627.  Menstruation,  p.  627.  Artificial  menopause,  p.  628.  Suppuration 
of  abdominal  wound,  p.  631.  Enlargement  of  scar,  p.  632.  Tenderness  of  scar,  p.  632. 
Alteration  in  position  of  intestines,  p.  632.     Hernia,  p.  633.     Ileus,  p.  633.     Fever,  p.  634. 

The  constantly  increasing  nnmber  of  gynecological  operations  during  the 
last  twenty  years  has  taught  the  medical  profession  many  things  in  connection 
with  them  which  were  not  at  first  understood.  One  of  these  facts  is  that  an 
uninterrupted  immediate  convalescence,  after  a  major,  or  even  a  minor  opera- 
tion, does  not  necessarily  imply  the  immediate  and  complete  recovery  of  perfect 
health  on  the  part  of  the  patient.  A  period  of  months,  and  in  many  cases  of 
a  year  or  more,  must  often  elapse  before  the  woman  who  has  been  relieved 
of  a  serious  pelvic  affection  really  reaches  normal  health  once  more.  This 
retardation  of  complete  recovery  arises  partly  from  the  shock  of  the  operation, 
but  it  is  far  more  frequently  the  result  of  a  general  depreciation  of  health 
wrought  by  years  of  suffering,  of  disturbed  sleep,  of  impaired  digestion,  of 
deprivation  of  fresh  air  and  exercise,  and,  in  many  cases,  of  constant  anxiety 
as  to  the  outcome  of  the  ailment.  To  rejuvenate  vital  forces  which  have,  for 
a  long  time,  been  more  or  less  profoundly  exhausted,  is  a  task  which  often  re- 
quires much  constant  care  and  attention  in  the  fateful  post-operative  period,  but 
it  is  one  well  worth  the  pains,  for  upon  the  management  or  the  mismanagement 
of  the  case  at  this  time  the  patient's  future  well-being,  in  a  large  measure, 
depends.  It  is,  as  a  rule,  upon  the  broad  shoulders  of  the  general  practitioner 
that  this  burden  falls,  and  happy  is  he  who,  in  these  days  of  multi-surgery, 
carries  this  burden  well.  Only  a  small  proportion  of  our  patients  are  able  to 
continue  to  command  the  services  of  the  specialist  who  has  done  the  operation 
for  any  considerable  period  afterwards ;  indeed,  many  of  those  who  come  from 
a  distance  are  in  the  utmost  haste  to  return  to  their  homes  as  soon  as  their 
immediate  recovery  is  assured  and  the  healing  of  the  wound  will  permit.  These 
patients  must,  of  necessity,  depend  entirely  upon  their  family  physician  for 
attention  during  the  (often  prolonged)  surgical  convalescences  of  which  I  speak. 

Let  me,  as  far  as  I  have  light  upon  this  important  subject,  dwell  upon  some 
of  the  important  features  of  a  home  convalescence. 

General  Rules. — First  and  foremost,  the  golden  rule  for  physician  and 
surgeon  alike  is  this :  ISTever  tell  a  patient  that  if  she  consents  to  any  surgical 
622 


GENEBAL    HYGIENIC    MEASUKES.  623 

operation,  however  necessary  it  may  be,  she  may  expect  at  once  to  be  a  well 
woman  when  she  rises  from  the  bed.  On  the  contrary,  inform  her  explicitly 
that  she  may  be  obliged  to  travel  the  road  towards  health  for  weeks,  or  months, 
or  sometimes  even  longer.  The  operation  must  never  be  recommended  as  a 
piece  of  legerdemain,  or  in  any  sense  a  sort  of  a  miracle,  but  simply  as  an 
absolutely  necessary  first  step  on  the  road  towards  health.  Until  this  first  step 
is  taken,  none  of  the  other  steps  towards  the  goal  can  follow.  Too  often  a 
feeling  of  magic  associated  with  the  operation  is  impressed  by  innuendo,  or 
perhaps  by  the  eager  attitude  of  the  doctor,  anxious  to  persuade  his  patient  to 
take  a  necessary  step  and  to  see  her  started  on  the  way.  Greater  care  in  stating 
the  case  correctly,  giving  the  operation  its  true  share  and  no  more,  will  cause 
fewer  heartburns  and  reproaches,  as  the  weary  patient  travels  the  tiresome  road 
towards  complete  convalescence. 

The  daily  life  of  the  patient  should  be  carefully  regulated 
for  at  least  a  year  after  an  operation  done  to  remove  a  cause 
of  protracted  ill  health.  This  necessity  for  subsequent  care  depends  not 
so  much  upon  the  extent  of  the  operation,  or  the  size  of  a  tumor  removed,  as 
upon  the  length  of  previous  suffering,  and  the  wearisome  vigils,  with  consequent 
depreciation  of  the  strength.  A  patient  of  this  kind  ought  for  several  months 
to  take  her  breakfast  in  bed,  and  then  not  to  dress  for  from  half  an  hour  to 
an  hour  later.  She  will  also  do  well  to  rest  for  half  an  hour  before  and  after 
each  meal,  and,  if  possible,  lie  down  for  an  hour  every  afternoon.  In  order 
to  get  the  benefit  of  her  afternoon  rest,  she  should  take  off  all  heavy  clothing, 
corsets,  and  shoes,  put  on  a  loose  wrapper,  and  lie  flat  on  the  bed  or  on  a  com- 
fortable lounge.  Most  restful  of  all  is  it  to  doff  the  day  clothes  down  to  the 
skin  and  to  put  on  a  nightgown.  It  is  not  advisable  to  read  anything  in  these 
brief  rest  periods,  for  if  she  can  sleep,  so  much  the  better.  She  ought  to  go 
early  to  bed,  not  later  than  ten  o'clock,  and  this  rule  should  be  inflexible.  Rest 
then  is  the  sheet  anchor  of  a  convalescence.  Many  persons  sleep  better  if  they 
take  some  light  refreshment  just  before  retiring,  a  glass  of  milk,  a  raw  egg,  a 
cup  of  hot  malted  milk,  a  sandwich,  or  some  crackers ;  occasionally,  on  the  other 
hand,  food  taken  just  before  sleep  disturbs  the  rest.  Bad  sleepers  and  over- 
nervous  women  sometimes  wake  up  in  the  wee  hours  and  keep  lonely  vigils 
until  they  are  utterly  exhausted;  for  such  cases  some  light  nourishment  taken 
when  they  wake  is  often  enough  to  induce  sleep  again. 

The  periods  of  rest  by  day,  as  well  as  that  by  night,  should  be  taken  in  a 
well-ventilated,  cool  room.  If  there  is  a  porch  available,  there  is  no  tonic  half 
so  good  as  the  bracing  fresh  air,  both  by  day  and  by  night,  with  the  body  well 
covered  in  a  cozy  bed.  I  believe  that  in  the  near  future  we  are  destined  to 
hear  much  more  about  the  out-of-door,  open-air  treatment  of  our  surgical  cases, 
both  immediately  after  the  operation  and  in  the  later  convalescence. 

The  appetite  and  the  digestion  call  for  careful  attention  and  super- 
vision, and,  as  a  rule,  it  is  a  good  plan  to  prescribe  some  form  of  bitter  tonic. 
The  following  I  have  often  found  useful : 


624  POST-OPERATIVE    CONDITIONS 

^   Extr.  gentian, 


_,         ~  ,         ■    ?■  aa cr    -i 

Extr.   calumb.,  )  '  &  •  j 

M.     Et.  pil.  i.     Mitte  tales  100.  . 

S.       One  pill  three  times  daily. 

If  there  is  much  anemia,  and  iron  is  needed,  I  know  nothing  better  than 
our  old  stand-by,  Blaud's  pill,  given  in  gradually  increasing  doses  (see 
Chap.  VI,  p.  156). 

Iron  may  also  be  given  effectively  in  combination  with  quinine  and 
strychnin. 

3^   Eerri  sulph.  exsic gr.  j 

Quin.  sulph gr.  ij 

Strych.  sulph gr.  -jV 

M.     Et.  pil.  i.     Mitte  tales  100. 

S.       One  after  each  meal. 

In  cases  where  nervous  exhaustion  is  well  marked,  nux  vomica 
in  increasing  doses,  as  recommended  by  Osier,  is  often  beneficial.  Begin  with 
ten  drops  in  water,  three  times  a  day,  and  increase  the  amount  by  one  drop 
with  each  dose,  until  the  patient  takes  twenty  or  even  as  much  as  twenty-five 
drops,  three  times  a  day.  If  there  is  any  twitching,  or  stiffness  of  the  jaws, 
the  remedy  must  be  discontinued  for  a  time  and  resumed  later,  in  a  smaller  dose. 

It  may  be  objected  that  such  a  careful  course  of  living  reduces  the  patient 
to  a  condition  of  semi-invalidism,  and  that,  hampered  by  such  restrictions,  she 
has  but  little  larger  opportunity  to  enjoy  life  than  before  the  operation,  which 
was  accepted  as  an  open  sesame  to  health.  The  wise  physician  will  make  answer 
that  the  operation  was  only  done  because  it  was  necessary  to  health,  and  that 
if  health  can  be  secured,  the  purchase  price  of  a  longer  or  a  shorter  convalescence 
is  not  a  matter  of  such  great  moment,  provided  the  wage  question  does  not 
have  to  enter  into  the  calculation. 

The  wise  patient  will  learn  that  rest  and  quietude  have  their  lessons  to 
teach,  and  that  time  thus  employed  may  be  even  more  profitably  spent  than 
days  of  bustling  activity.  It  often  happens  that  she  who  thus  rests  much  alone, 
for  the  first  time  faces  the  real  issues  of  life,  and  is  for  the  first  time  startled 
to  hear  the  still  small  voice  of  the  long-stifled  inward  monitor,  more  potent  in 
the  formation  of  character  than  all  the  obtrusive  noisy  activities  of  the  world 
of  society.     He,  too,  is  a  wise  physician  who  seeks  to  inculcate  this  lesson. 

The  plan  I  have  thus  briefly  outlined  will  be  modified  and  adapted  to  meet 
the  necessities  of  individual  cases.  Write  over  the  door  of  every  convales- 
cent woman  festiyia  lente,  and  let  it  be  the  parting  greeting  after  each  visit. 
The  physician  Avill  do  well  to  have  such  an  understanding,  not  only  with  the 
patient,  but  with  her  relatives  as  well,  in  order  that,  realizing  the  benefits  to 
accrue,  they  may  lend  their  hearty  cooperation  and  refrain  from  vain  imagin- 
ings that  because  the  patient  is  not  immediately  restored,  the  operation  has  not 


CONSTIPATION.       FOOD.        EXERCISE.  625 

been  a  success.  There  is  no  greater  charity  for  a  poor,  self-supporting  woman 
•than  to  ^ive  her  a  good  long  holiday,  in  the  country  if  possible.  Some  short- 
sighted philanthropic  souls  unfortunately  take  it  for  granted  that  into  the  hos- 
pital and  out  again  is  all  that  the  occasion  calls  for,  and  that  anything  short 
of  immediate  recovery  is  a  species  of  ingTatitude  on  the  patient's  part. 

Constipation. — For  some  time  after  most  abdominal  operations  the  patient 
is  apt  to  be  troubled  with  a  constipation,  which  may  be  obdurate ;  the  physician 
must  see  to  it  that  the  bowels  are  kept  regular.  The  means  of  doing  this  are 
discussed  at  length  in  Chapter  VIII,  and  I  Avill  not  repeat  them  here  further 
than  to  remark  that  I  have  found  cascara  sagrada  the  best  drug,  both  in 
the  period  of  immediate  recovery  as  well  as  in  the  more  remote.  The  dose  of 
the  fluid  extract  is  ten  to  thirty  drops,  and  of  the  tincture  half  a  teaspoonful  to 
two  dessertspoonfuls.  It  not  infrequently  happens  that  cases  where  a  large 
dose  is  needed  in  the  beginning  are  able  to  decrease  it  after  a  little  while,  and 
by  continuing  to  diminish  it  by  degrees,  a  normal  condition  of  the  bowels  is  at 
last  established,  which  requires  no  interference.  I  would  repeat  Sanger's  urgent 
injunction — away  with  drugs,  use  general  massage,  give  electricity  over  the  ab- 
domen, and  insist  on  a  natural  evacuation,  even  if  it  takes  days  to  get  nature  to 
do  it  unaided.  This  course  takes  courage,  but  it  has  the  backing  of  our  best 
men.     If  it  is  tried,  it  must  be  with  conviction. 

If  the  physician  is  willing  to  fight  the  battle  without  drugs,  but  finds  that 
the  general  tonic  remedy  has  not  been  sufficient  to  regulate  the  habit,  I  find 
the  simplest  and  best  of  all  means  of  aiding  the  patient  is  the  use  from  time 
to  time  of  a  flaxseed  enema.  This  is  made  in  the  following  manner:  Two 
tablespoonfuls  of  the  whole  seeds  are  put  in  a  pint  of  cold  water,  brought  to  the 
boiling  point,  and  boiled  for  ten  minutes.  The  mucilaginous  solution  thus  made 
is  strained  through  a  fine  sieve  and  allowed  to  stand  until  tepid,  when  it  is 
injected  slowly  into  the  bowel.  The  best  time  to  do  this  is  about  half  an  hour 
after  breakfast.  An  enema  of  this  kind,  being  similar  in  consistency  with  the 
bowel  movement,  is  calculated  to  have  a  soothing  effect  upon  the  mucosa  of  the 
bowel. 

Food  is  an  important  factor  in  the  treatment,  and  daily  evacuations  must 
not  be  expected  where  only  small  amounts  are  taken.  The  diet  ought  to  be 
looked  after,  up  to  complete  recovery ;  it  should  be  simple  and  nutritious,  and 
not  too  concentrated.  A  little  food  between  meals  serves  to  prevent  exhaustion ; 
it  acts  also  as  a  mild  diversion,  helping  to  divide  up  the  day  pleasantly,  and  to 
relieve  the  tedium  of  waiting  for  the  health  which  sometimes  seems  to  come  on 
leaden  wings. 

Exercise. — The  question  of  exercise  during  a  protracted  convalescence  is  im- 
portant. At  first,  a  little  at  home,  then  out  onto  the  porch,  and  then  perhaps 
a  drive,  or  a  walk  for  a  short  distance.  When  the  means  are  limited,  the  trolley 
cars  often  offer  diversion  and  variety  with  plenty  of  fresh  air.  With  the  grow- 
ing improvement,  regular  out-door  exercise  or  employment  of  a  character  suited 
to  strength  and  taste  should  be  encouraged.  It  is  a  mistake,  however,  to 
41 


626  POST-OPEKATIVE    CONDITIOlSrS. 

advise  anytliing  strongly  against  natural  inclinations  and  tastes.  Light  gar- 
dening, when  available,  is  a  most  beneficial  occupation.  Tennis  is  too 
strenuous  an  exercise,  but  croquet  and  golf  are  excellent.  When  the  patient 
is  free  to  do  as  she  pleases,  it  is  often  a  wise  plan  to  send  her  for  a  few  months 
to  some  mountain  or  sea-side  resort,  v\'here  she  can  have  plenty  of  op- 
portunity for  exercise  in  the  fresh  air,  coupled  with  pleasant  companionship. 
Lifting  and  straining  must  be  forbidden  for  about  a  year  after  a  laparotomy, 
in  order  not  to  strain  an  abdominal  scar. 

Alternate  rest  and  exercise,  duly  proportioned  and  supplementing 
one  another,  are  by  far  the  most  valuable  means  we  possess  of  restoring  com- 
plete health.  And  although  these  simple  natural  processes  are  by  no  means  so 
dramatic  and  so  impressive  as  some  of  the  other  resources  of  our  medical  arma- 
mentarium, they  are,  nevertheless,  by  far  the  most  valuable;  and,  albeit  they 
seem  so  simple,  by  far  the  most  difficult  to  use  correctly  and  successfully. 

Local  Pain. — Of  all  the  distressing  sequelae,  pain  is  the  most  likely  to 
plunge  the  patient  who  has  been  through  an  operation  into  despondency,  and 
to  delay  the  convalescence.  It  is  a  fact  that  an  habitual  pain  does  not  by  any 
means  always  disappear  immediately  after  the  operation,  even  when  the  cause 
has  been  removed.  As  a  rule,  it  is  relieved  at  once,  but  where  it  has  existed 
for  years,  and  especially  where  much  morphin  has  been  given,  the  "  pain-habit  " 
may  be  established,  and  it  takes  time  and  close  attention  to  break  it  off.  The 
experienced  physician  will  always  assure  his  patient  in  advance  that  the  con- 
tinuance of  a  certain  amount  of  suffering  is  not  inconsistent  with  its  complete 
disappearance  in  the  near  future.  He  must  exercise  extreme  caution  in  using 
remedies  for  pain  at  this  time,  as  the  risk  of  a  drug  habit  is  as  great  as 
before  the  operation.  A  patient  of  some  moral  fibre  will  often  bear  the  pain 
cheerfully  when  assured  that  it  will  soon  go.  If  she  is  hypersensitive,  nervous, 
and  lacking  in  force  of  character,  it  may  be  necessary  to  give  some  relief,  but 
it  must  not  be  any  form  of  opium,  and  it  ought  not  to  be  a  drug;  it  should 
come  from  the  moral  force  of  the  physician  himself,  as  he  upholds  and  carries 
the  weakling  along,  day  by  day,  until  she  can  at  last  stand  alone.  If  any  drug 
is  given,  it  ought  to  be  in  the  physician's  hands  and  not  in  the  patient's,  who 
is  always  safer  if  she  does  not  know  what  she  is  taking. 

The  worst  sufferers  and  the  most  difiicult  to  control  for  some  time  after  an 
operation  are  those  women  who  have  been  in  the  habit  of  taking  morphin  to 
relieve  their  pain.  I  have  cured  a  great  many  morphin  maniacs  by  doing  an 
operation  and  then,  after  the  patient  is  confined  to  her  bed  and  I  have  entire 
control  of  her,  I  do  not  allow  any  sedative  whatever  to  be  given.  There  may 
be  a  great  deal  of  suffering  for  a  few  days  or  a  week,  but  she  comes  out  of  her 
trial  impressed  by  the  fact  that  she  is  able,  after  all,  to  bear  some  real  severe 
pain  without  the  drug.  In  this  way  a  certain  amount  of  moral  force  is  de- 
veloped in  a  character  which  seemed  before  to  be  lacking.  In  other  cases  the 
habit  is  best  broken  off  gradually.  The  patient  may  be  too  weak  and  prostrated 
by  her  disease  to  stand  the  immediate  withdrawal  of  a  drug  which,  in  some 


HEADACHE.       MENSTRUATION.  627 

cases,  she  has  been  taking  in  large  amounts,  as  much  as  fifty  grains  per  day. 
In  such  cases  the  large  part  of  the  battle  consists  in  the  personal  interest  shown 
by  the  physician,  and  in  the  moral  support  he  gives  the  patient  in  keeping  up 
her  courage  as  she  joins  with  him  in  the  fight  for  emancipation  from  the  en- 
slaving habit.  The  battle  with  the  drug  can  always  be  won  if  the  physician 
adopts  the  right  attitude,  and  secures  first  the  confidence  of  the  patient  and 
then  her  cooperation.  It  is  most  important  during  the  stress  of  the  battle  to 
keep  careful  watch  upon  any  visiting  relatives,  friends,  or  old  nurses,  who  may 
undo  all  the  good  that  has  been  accomplished  by  bringing  in  the  drug  in  an 
underhand  way. 

There  are  a  certain  class  of  hysterical  patients  who  are  inclined  to  exag- 
gerate suffering  and  who  refuse  to  acknowledge  the  relief  they  have  received ; 
these  call  for  extreme  patience  and  a  calm  judicial  treatment  of  their  com- 
plaints, coupled  with  persistence  in  a  right  course  when  it  is  once  carefully 
mapped  out. 

Headache. — Besides  the  pelvic  suffering  associated  with  the  particular  lesion 
from  which  the  patient  has  suffered,  there  is  sometimes  a  tendency  to  head- 
ache, which  only  time  can  overcome.  These  headaches,  as  a  rule,  are  the  ex- 
pression of  an  exhausted  nervous  system,  whose  capacity  for  resistance  has  been 
sapped  by  long-continued  ill  health;  they  disappear  as  vigor  comes  back  and 
the  nervous  system  regains  its  tone.  In  some  cases,  nux  vomica  in  substan- 
tial doses  (twenty  to  twenty-five  drops)  Avill  do  much  to  give  relief,  but  the  best 
dependence  is  time,  with  fresh  air,  and  the  slower  process  of  building  up  the 
general  health.  Local  pains  and  headaches  are  often  good  gauges  of  the  pa- 
tient's staying  powers.  If  the  pain  comes  on  after  walking,  driving,  or  any 
other  exertion,  it  may,  as  a  rule,  be  taken  as  an  indication  that  the  patient  has 
rather  exceeded  the  wise  limit  of  her  strength ;  and  if,  in  time,  the  headaches 
show  no  tendency  to  decrease  in  severity  or  frequency,  it  is  evident  that  the 
nervous  system  is  still  over-taxed  and  the  cause  must  be  sought  out. 

If  there  is  no  steady  improvement  in  the  patient's  general  or  local  condition 
from  month  to  month,  it  is  always  best  to  communicate  with  the  specialist  who 
had  her  under  his  care ;  but  if  the  improvement  is  steady,  however  slow  it  may 
be,  there  is  no  reason  for  anxiety. 

Menstruation. — Most  of  the  affections  in  women  for  which  pelvic  operations 
are  performed  are  accompanied  by  disturbances  of  menstruation,  and 
it  may  be  some  time  before  the  function  is  again  normal  in  its  performance, 
even  though  the  abnormal  conditions  which  led  to  its  disturbance  are  removed. 
All  such  patients  must  be  extremely  careful  during  menstrua- 
tion for  a  considerable  time.  It  is,  as  a  rule,  best  at  first  to 
remain  in  bed  as  long  as  the  flow  lasts,  and  the  ordinary  habits  of 
life  at  that  time  must  be  resumed  with  caution.  For  some  patients  it  is  sufii- 
cient  to  spend  the  first  twenty-four  hours  of  the  period  in  bed.  Curettage 
of  the  uterus  is  almost  always  followed  by  some  disturbance  of  menstrua- 
tion, especially  as  regards  amount,  which  is  often  excessive  for  one  or  two 


628 


POST-OPERATIVE    CONDITION'S. 


periods,  althougli  sometimes  the  flow  is  temporarily  absent  or  scanty.  When 
the  curetting  has  been  done  for  the  relief  of  menorrhagia,  it  often  happens 
that  the  first  menstrual  period,  and  it  may  be  the  second  and  the  third,  will  be 
as  jDrofnse  as  before  the  oi^eration,  or  even  more  so,  a  fact  which  is  apt  to 
excite  apprehension  in  the  patient's  mind,  lest  the  operation  has  been  a  fail- 
ure. It  is  important,  therefore,  for  the  physician  to  assure  her  that  the  diffi- 
culty is  one  of  common  occurrence  and  will  subside  spontaneously  in  the  course 
of  a  few  months.  It  is  best  for  the  physician  to  tell  the  patient  before  any 
pelvic  operation  that  she  must  not  expect  her  menstrual  period  to  be  normal 
immediately  afterwards.  In  this  way  he  will  relieve  a  gTeat  deal  of  appre- 
hension when  the  period  is  delayed,  or  when  it  is  excessive. 

Artificial  Menopause. — When  an  artificial  menopause  has  been  in- 
duced, the  patient  will  experience  more  or  less  of  the  discomforts  incidental  to 
the  normal  change  of  life.  The  severity  is  in  proportion  to  the  age  of  the. 
patient;  that  is  to  say,  the  nearer  she  is  to  the  normal  menopause  the  less  will 
be  the  discomfort,  but  if  the  artificial  cessation  of  menstruation  occurs  early  in 
life,  the  disturbances  accompanying  it  are  most  distressing.  They  are  generally 
first  experienced  about  the  time  when  the  next  period  after  the  operation  should 
appear,  and  they  usually  continue  for  eighteen  months  to  two  years.  In  excep- 
tional cases,  they  last  for  as  much  as  five  years.  Waves  of  heat  and 
flushes  passing  over  the  body  at  intervals  like  a  draught  of  hot  air  are  the 
commonest  of  these  manifestations;  sometimes  the  face  is  reddened  and 
there  may  be  a  feeling  of  giddiness.  Some  patients  complain  of  a  sen- 
sation of  a  gulf  suddenly  yawning  before  them,  accompanied 
by  a  dread  of  falling  into  it.  These  sensations  last  for  a  few  seconds 
to  several  minutes,  and  after  they  subside,  there  is  a  feeling  of  great  ex- 
haustion, while  the  skin  is  covered  with  perspiration.  Some  per- 
sons suffer  from    great    depression,    almost  amounting  to    melancholia, 

while  others  are  troubled 
with  constantly  recurring 
headaches.  Sometimes  the 
symptoms  recur  at  regular 
intervals  corresponding  to  the 
menstrual  periods;  in  other 
cases  there  is  no  definite  pe- 
riodicity. Obscure  rheu- 
matic pains  in  different 
parts    of    the    body     are     a 

frequent    symptom,    and  lo- 

FiG.   162.  —  Diagram  showixg  XoDrxE  of  Ovahiax  Tissue  1  "         1  1  -P  f  1 

.\djacext   to   the   Right  Uterixe  Cohxu   axd   Causixg    caiizeci        C  Clem  a        01  tUC 

Mexstrtjatiox.     In  this  case  a  double  oophorectomv  had    lionrlc     o-nrl     -Poof    moTT    l^o  r,h 

presumably  been  done.  ^  naUClb     anQ.ieei    may     DC  OD- 

served. 
I  liave  re]ieatedly  had  patients  come  to  me,  more  frequently  ten  or  fifteen 
years  ago  than  of  late,  who  liad  been  operated  upon  for  some  pelvic  disease, 


ARTIFICIAL    MENOPAUSE. 


629 


Fig.  163. — Diagram  showing  the  Results  of  Hematoma  For- 
mation AND  Infection  Arising  from  a  Nodule  such  as 
SHOWN  IN  Fig.  162. 


whicli  in  the  judgment  of  the  surgeon  had  necessitated  the  removal  of  both 
ovaries,  who  yet  continued  to  menstruate  regularly.      After  some  experience 
with  this  class  of  cases,  1  was  able  to  aver  that  on  opening  the  abdomen  I  would 
find  traces  of  ovarian  tissue 
and  corpora  lutea  at  one  or  ^au^^^z^^^i 

other  cornu  uteri  (see  Fig. 
1G2),  in  the  form  of  a  few 
little  nodules  cut  off  close  to 
the  ligature.  Sometimes  this 
little  bit  of  ovarian  tissue 
does  a  great  deal  of  mischief 
by  forming  a  hematoma  or 
a  cyst  (see  Fig.  163),  and 
contracting  adhesions  to  the 
neighboring  loops  of  intes- 
tines. In  cases  of  this  kind 
there  has  often  been  a  local- 
ized infection. 

Schmalfuss  ("  Zur  Castration  bei  l^eurosen,"  Arcli.  f.  Gyn.,  1885,  vol.  26, 
p.  1)  divides  the  neuroses  occurring  under  these  circumstances  into  the  follow- 
ing classes: 

(1)  Symptoms  referred  to  the  lumbar  section  of  the  spinal 
cord,  such  as  throbbing  and  pain  in  the  back,  pain  in  the  iliac  region,  pain 
extending  from  the  back  to  the  abdomen  and  radiating  down  the  thighs,  pressure 
in  the  pelvis,  downward  tugging,  anesthesia  or  hyperesthesia  of  the  vagina  and 
vulva,  and  pain  on  urination  and  defecation. 

(2)  Neurotic  symptoms  localized  in  different  parts  of  the 
body,  such  as  cardialgia,  pressure  in  the  epigastrium,  sensation  of  fulness, 
belching,  vomiting,  and  globus  hystericus. 

(3)  A  distinct  neuropathic  condition,  with  general  pain,  vaso- 
motor disturbance,  vicarious  menstruation,  respiratory,  gastric,  and  intestinal 
attacks  of  various  sorts,  cramps,  and  epileptiform  convulsions. 

Of  all  the  sequelEe  following. the  production  of  an  artificial  menopause,  in- 
sanity is  the  most  important.  It  may,  however,  occur  after  any  pelvic  opera- 
tion, and  even  after  one  done  for  some  condition  belonging  to  general  surgery. 
The  class  of  women  most  apt  to  become  insane  under  such  conditions  are  those 
who  have  well-marked  neurotic  temperaments,  and  in  women  of  this  kind, 
especiallv  if  there  is  any  family  history  of  mental  disease,  the  induction  of  an 
artificial  menopause  for  any  reason  less  important  than  the  preservation  of  life 
would  seem  to  be  contraindicated. 

The  treatment  of  the  symjDtoms  accompanying  the  artificial  meno- 
pause does  not  differ  in  any  way  from  that  of  the  same  conditions  occurring 
with  a  normal  change  of  life,  and  will  be  found  described  in  Chapter  III 
(see  p.  90). 


630  POST-OPERATIVE    CONDITIONS. 

I  have  been  able  to  give  a  great  deal  of  relief  in  these  cases  by  the  adminis- 
tration of  lutein  in  twenty  grain  doses,  three  times  a  day;  in  some  cases  given 
continuously,  in  others  given  periodically  when  the  discomforts  are  greatest, 
and  continued  for  about  ten  days  at  a  time.  The  lutein  is  made  by  squeezing 
out  the  corjDora  lutea  from  the  ovaries  of  the  pig  obtained  at  the  slaughter- 
house. The  corpora  are  then  rapidly  dried,  powdered,  and  compressed  into 
tablets.  In  many  instances  I  have  obtained  remarkable  results  from  the  use 
of  this  remedy.  I  have  not  found  the  ordinary  ovarian  extract  made  from 
the  dried  tissues  of  the  ovary  itself  of  any  particular  value. 

There  is  one  prescription,  which  I  give  here,  that  I  have  found  to  be  most 
beneficial  in  the  class  of  women  now  under  discussion: 


1 

30 

1 

300 


^   Strych.  sulpli gr 

Atrop.  sulph gr 

Extr.  calumb gT.  j 

M.     Ft.  pil.  i.     Mitte  tales  30. 

S.       One  pill  three  times  daily. 

Phlebitis. — Phlebitis  is  an  inflammatory  affection  of  the  veins,  resulting 
in  the  formation  of  a  thrombus,  by  which  the  lumen  of  the  vein  becomes 
occluded.  In  the  milder  forms  of  phlebitis  the  occlusion  is  only  temporary, 
lasting  little  over  a  couple  of  weeks,  but  in  the  severer  gTades  the  venous 
lumen  is  permanently  occluded,  and  the  return  blood  is  compelled  to  find 
new  channels. 

There  are  two  forms  of  phlebitis,  the  septic  and  the  non-septic.  Sep- 
tic phlebitis  is  especially  noted  in  puerperal  cases  and  after  septic  opera- 
tions, and  is,  therefore,  but  rarely  encountered  as  a  sequel  to  gynecological 
procedures.  I  speak  here  only  of  those  forms  of  phlebitis  which  are  seen  in  the 
lower  abdomen  and  the  legs,  more  particularly  in  the  femoral  veins. 

Phlebitis  may  begin  in  the  deep  veins  of  the  pelvis,  as  evidenced  by  the 
fever  and  location  of  the  pain  before  the  onset  of  the  femoral  phlebitis.  The 
commonest  site  of  the  pain  and  tenderness  at  first,  however,  is  over  the  femoral 
vein  right  under  Poupart's  ligament,  from  which  point  they  extend  in  a  char- 
acteristic line  down  the  thigh,  follow^ing  the  great  vessels.  Kronig  believes  that 
the  phlebitis  usually  begins  in  the  femoral  vessels  and  that  it  is  mechanical  in 
its  genesis.  The  usual  time  of  onset  is  about  two  weeks  after  the  operation  of 
which  it  is  the  sequel. 

The  cardinal  and  distressing  signs  of  phlebitis  are: 

(1)  'Pain  in  the  pelvis  and  the  thigh  affected. 

(2)  Edema  of  the  leg. 

(3)  Embolism,  formed  by  the  thrombus  breaking  loose  and  migrating  to 
the  lungs. 

Fever,  usually  of  a  low  grade  and  short  duration,  is  observed  preceding  and 
accompanying  the  attack. 


PHLEBITIS.       SUPPUKATION    OF    THE    WOUND.  Q3J 

The  danger  of  embolism  is  over  before  the  patient  leaves  the  hospital,  and 
therefore  does  not  concern  the  general  practitioner  in  his  management  of  the 
case  after  she  has  returned  to  her  home. 

I  have  observed  phlebitis  after  the  following  operations : 

Hystero-myomectomy • 24  times 

Removal  of  the  vermiform  appendix 2      " 

Removal  of  ovarian  cysts. 8      " 

Exploratory  laparotomy 3      " 

Salpingo-oophorectomy    6      " 

Hysterectomy  for  cancer 4      " 

Suspension  of  the  uterus 7      " 

Suspension  of  the  kidney 3      " 

Repair  of  the  relaxed  vaginal  outlet 10      " 

Opening  and  draining  of  a  pelvic  abscess 1  time 

The  treatment  of  phlebitis  is  never  one  of  active  local  therapy.  A 
patient  suffering  from  it  must  not  be  hurried  home  from  the  hospital,  but 
should  stay  at  least  five  weeks  in  bed  on  her  back  after  the  onset  of  this  trouble- 
some complication.  When  the  patient  reaches  home  she  is  liable  to  suffer  from 
pain  and  from  the  swelling.  The  course  of  treatment  should  then  be,  first  of 
all,  expectant.  She  must  understand  that  no  great  improvement  is  observable, 
as  a  rule,  in  a  period  of  time  less  than  eight  to  twelve  months.  Patience  must 
therefore  be  inculcated  from  the  first.  An  elastic  bandage  applied  each  day 
before  rising  gives  much  relief  by  supporting  the  limb  and  preventing  edema. 
The  patient  should  spend  much  of  her  time  in  rest,  and  keep  the  limb  elevated. 
Massage  is  helpful  in  restoring  the  circulation.  If  there  is  much  swelling  of 
the  superficial  veins  during  convalescence  it  should  not  be  interfered  with.  I 
know  of  a  case  in  which  the  enterprising  doctors  dissected  out  the  swollen  veins 
of  the  thigh  and  abdomen  which  formed  the  relief  circulation;  the  result  was 
a  gangrene  of  the  thigh  calling  for  a  hip- joint  amputation.  I  do  not  recall 
any  case  of  phlebitis  which  has  not  recovered,  though  the  improvement  in  some 
cases  has  been  not  less  than  two  years  in  coming. 

Suppuration  of  the  Wound. — A  suppuration  developing  in  the  wound  some 
time  after  the  operation  is  always  a  sign  of  a  lingering  infection  which,  as  a 
rule,  has  developed  in  the  post-operative  period.  This  suppuration  may  occur 
in  the  abdominal  wall  covering  the  wound,  or  arise  from  the  deeper  parts.  The 
superficial  suppurations,  as  a  rule,  arise  from  the  use  of  non-absorbable  suture 
material,  chromicized  catgut,  silk,  silver  wire,  or  silkworm-gut.  In  the  days 
Avhen  it  was  customary  to  tie  off  the  pedicles  with  silk  (especially  braided  silk), 
it  was  common  to  note  the  fistula?  discharging  pus,  due  to  infection  of  the  deep 
ligatures.  Every  case  of  suppuration  should  be  treated  seriously.  In  the  acute 
stage,  poultices  should  be  applied,  and  as  soon  as  the  wound  is  sufficiently 
opened,  it  should  be  carefully  examined  with  a  crochet  hook  to  see  if  there  is 


532  POST-OPEEATIVE    CONDITIONS. 

a  ligature  within,  wbicli  can  be  eauglit  and  ^yitlldra^vn.  It  is  always  best  for 
the  general  practitioner  to  be  present  at  operations  upon  bis  patient,  and  to  be 
fully  informed  at  tbe  time,  both  as  to  the  exact  operation  done  and  the  charac- 
ter of  the  sutures  and  ligatures  used.  In  this  way  he  will  be  able  to  form  a 
better  idea  as  to  the  cause  of  the  suppuration  should  it  occur.  Some  of  the 
late  suppurations  arise  from  the  slow  healing  of  a  drainage  tract,  in  cases  in 
which  it  has  been  necessary  to  drain  the  pelvis,  because  of  an  extensive  infec- 
tion. If  the  suppuration  is  more  than  a  slight  abscess,  it  would  be  best  to  give 
the  patient  an  anesthetic,  to  open  the  wound  freely,  determine  its  cause  and 
remove  it,  and  then  to  let  the  wound  close  up  with  free  drainage.  Small  areas 
may  be  cleaned  out  and  douched  with  carbolic  acid,  in  the  hope  of  a  rapid 
recovery. 

Enlargement  of  the  Scar. — It  frequently  happens  that  a  patient  who  has  been 
very  thin,  even  emaciated,  for  a  long  time  before  a  radical  operation,  in  conse- 
quence of  continued  ill  health,  begins  to  gain  flesh  as  soon  as  her  ailments  are 
relieved.  If  she  gains  in  weight  rapidly,  the  scar  will  yield  from  side  to  side, 
as  the  girth  of  the  abdomen  increases,  until  it  becomes  as  much  as  two  centi- 
metres (three-fourths  of  an  inch)  or  more  in  width;  moreover,  it  often  becomes 
pitted,  pigmented,  and  unsightly.  I  know  of  nothing  to  improve  this  condition, 
and  I  do  not  believe  that  any  kind  of  bandage  does  any  good.  There  is  a 
tendency,  especially  among  negTesses,  to  the  formation  of  keloids  in  the  scar 
tissue. 

Tenderness  of  the  Scar. — "While  the  wound  is  young  and  pink,  it  is  somewhat 
common  for  the  patient  to  complain  of  soreness,  itching,  or  shooting 
pains  in  the  scar.  In  nervous  women  this  tenderness  may  persist  for  years. 
Eelief  is  best  obtained  by  gentle  massage  and  by  arranging  the  clothing  so 
as  to  avoid  direct  pressure  on  the  sensitive  area. 

Alteration  in  the  Position  of  the  Intestines. — One  of  the  sequela?  brought 
about  shortly  after  the  operation  is  alteration  in  the  position  of  the  intestines, 
and  it  may  continue  to  give  trouble  for  a  considerable  time.  Additional  loops 
of  intestine  drop  down  into  the  pelvis  in  order  to  fill  the  vacated  space,  and 
adhesions  of  the  omentum  and  intestine  over  the  inner  surface  of  the  peri- 
toneum are  apt  to  be  formed.  These  adhesions  do  not,  as  a  rule,  give  rise  to 
serious  trouble,  though  in  a  certain  number  of  cases  they  occasion  pain  in  the 
lower  abdomen,  with  tormina,  nausea,  and  vomiting  from  constant  dragging 
upon  the  transverse  colon  and  pulling  the  stomach  downward.  In  some  cases 
they  occasion  obstinate  constipation.  As  a  rule,  disturbances  of  this  kind  do 
not  require  any  interference  and  pass  away  of  themselves  before  long,  but  they 
are  occasionally  so  severe  as  to  make  it  best  to  send  the  patient  back  to  the 
surgeon  who  operated,  in  order  that  he  may  decide  whether  it  is  necessary  to  re- 
open the  abdomen  for  relief.  The  release  of  the  adhesions  with  an  aseptic 
closing  of  the  abdomen  has  been  followed  by  immediate  disappearance  of  all 
bad  symptoms  in  those  cases  where  they  have  been  severe  enough  to  require 
operative  procedures. 


HERNIA.       ILEUS.  633 

Hernia. — The  most  serious  of  all  post-operative  local  conditions  is,  of  course, 
a  ventral  hernia  in  the  abdominal  scar.  The  number  of  such  hernias  becomes 
less  every  year,  with  the  progressive  improvement  of  surgical  technic  and  the 
careful  training  of  operators ;  nevertheless,  they  do  occasionally  occur,  especially 
when  the  patient  has  overexerted  herself  before  recovery  was  complete,  and 
when  increase  in  weight  has  been  unusually  rapid.  There  is  only  one  form  of 
treatment  which  can  be  relied  upon  for  permanent  relief,  namely,  radical 
operation,  and  such  cases  should  be  placed  in  a  surgeon's  hands  as  soon  as 
possible.  Palliative  treatment  by  means  of  supports  gives  temporary  re- 
lief, but  as  the  tendency  of  all  such  hernias  is  to  grow  larger,  it  can  be  of  no 
permanent  benefit. 

Ileus. — Among  the  more  serious  late  sequelae  is  an  ileus,  or  a  post-operative 
obstruction  of  the  bowels.  This  untoward  sequel  may  develop  from  little  begin- 
nings, such  as  a  rumbling  and  twisting  with  pain,  which  grows  gradually  worse 
from  week  to  week ;  or  it  may  come  on  as  an  acute  obstruction.  Hand  in  hand 
with  the  difficulty  in  moving  the  bowels  go  the  pains  or  tormina.  The  pain  is 
developed  by  the  contractions  in  the  bowel,  proximal  to  the  obstruction ;  in  thin 
patients  the  pattern  of  the  contracting  loops  can  be  traced  on  the  surface  of  the 
abdomen.     With  the  contraction,  more  or  less  gurgling  is  heard. 

Such  a  difficulty  arises,  as  a  rule,  from  the  post-operative  adhesions,  either 
to  the  abdominal  wall  about  the  incision,  or  to  the  seat  of  the  operation,  as  an 
ovarian  or  a  uterine  stump.  Sometimes  it  is  due  to  a  broad  film  of  adhesions 
(forming  immediately  after  the  operation)  which  by  the  movements  of  the 
bowel  has  been  rolled  together  to  form  a  powerful  lymph  as  strong  as  a  rope. 
As  a  rule,  such  difficulties  show  themselves  while  the  patient  is  still  in  the 
hands  of  the  surgeon,  who  must  continue  to  supervise  his  patient  until  he  is 
sure  no  late  accident  is  liable  to  arise. 

If  mild  remedies  do  not  succeed  in  keeping  the  patient's  bowels  open,  and 
if  the  tendency  toward  ileus  is  clearly  progressive  for  a  few  days,  the  practi- 
tioner ought  not  to  wait  long,  but  should  put  his  patient  again  in  the  care  of 
the  surgeon,  in  order  that  he  may  carefully  consider  the  question  whether  or 
not  the  abdomen  ought  to  be  opened  to  liberate  all  adhesions.  It  is  better  to 
err  on  the  side  of  early  action  in  these  cases,  than  to  wait  until  long  and  ex- 
hausting efforts  have  robbed  the  patient  of  much  of  her  strength  before  making 
the  incision  and  undertaking  what  may  prove  to  be  a  long  and  difficult  operation. 

The  cancer  cases  which  are  sent  back  by  the  surgeon  to  die  in  the  hands 
of  the  general  practitioner  must  not  be  neglected  by  him.  They  ought,  on 
account  of  their  condition,  to  receive  even  more  constant  tender  care  than  the 
more  promising,  hopeful  cases.  I  have  already  dwelt  on  these  cases  in  the 
chapter  on  inoperable  cancer  of  the  womb  (see  Chap.  XXI).  In  all  of  these 
cancer  cases,  it  is  important  to  keep  the  parts  clean  with  repeated  douches  and 
applications  where  the  disease  can  be  reached,  to  keep  the  bowels  open,  to  keep 
up  nutrition,  and  as  long  as  the  patient  is  able  to  bear  it,  to  keep  her  in  the 
fresh  air.     Mild  sedatives  may  be  used  to  relieve  the  pains  at  first,  and  later 


634  POST-OPEEATIVE    CO^'DITIO>"S. 

morpliin  will  have  to  be  used,  but  it  is  be~t  tri  priitp'one  tlii?  period  as  long  as 
possible,  in  order  to  husband  ciur  resijurce-  in  'it-Lding  v.-ith  the  pains  during 
the  last  few  months.  The  morphin  should  \>e  used  at  first  as  sparingly  as  pos- 
sible, in  doses  of  an  eighth  of  a  grain,  gradually  increased  according"  to  neces- 
sity, in  Tvhatever  lLj-c-  niay  }>e  required  to  relieve  the  suffering. 

Fever  is  a  late  sequel  -which  the  general  ^jractitioner  riught  not  to  see.  Any 
fever  observed  at  a  late  date  can  l)e  but  the  contintiance  of  some  post-operative 
infection.  Tvhich  must  have  manifested  itself  vrhile  the  patient  was  still  in  bed. 
l^o  siu'geon  ever  discharges  a  febrile  patient.  If  fever  arises  after  a  normal 
convalescence,  the  physician  must  look  fca-  n.alaria.  and  carefully  consider 
typhoid,  or  some  other  new  affection.  One  'of  ri;v  i  ;,Tif>nts  v.-h'j  had  a  suspension 
of  the  uterus,  as  she  was  getting  well  deveLj]--;  n.  liiysterious  fever  which  I 
cotild  ncit  explain  in  any  way.  She  left  my  care  and  carne  back  six  months 
later  with  a  tertiary  syphilis  I 

In  numerous  cases  I  have  seen  malaria  break  otit.  and  typhoid  fever,  too, 
in  the  course  of  the  convalescence,  ptizzling  f'jr  a  time  all  who  were  caring  for 
the  invalid.     Latent  tul:>erculosis  mav  also  manifest  itself  in  this  wav. 


CHAPTER    XXVII. 

DISEASES   OF  ADVANCED  AGE. 

Marriage,  p.  636.  Pruritus,  p.  636.  Cancer  of  the  clitoris  and  vulva,  p.  636.  Tumor  of  the 
urethra,  p.  636.  Hypersensitive  vaginal  orifice  and  atrophy  of  the  vagina,  p.  637.  Vaginitis 
of  atrophic  character,  p.  637.  Cancer  of  the  womb,  p.  638.  Pyokolpos,  pyometra  and 
physometra,  p.  639.     Fibroid  tumors,  p.  640.     Ovarian  tumors,  p.  640. 

It  is  universally  and  naturally  conceded  that  an  advanced  age  ought  at  least 
to  afford  immunity  from  all  those  diseases  which  affect  the  sexual  organs,  which 
have  done  their  work  and  passed  into  a  condition  of  presumably  innocuous 
desuetude. 

For  this  reason,  any  signs  of  activity  in  the  pelvic  organs  of  the  old  or  any 
apparent  "  rejuvenescence  "  in  the  form  of  a  bloody  discharge  is  naturally 
viewed  with  suspicion  and  alarm. 

There  is  reason,  therefore,  whether  on  the  ground  of  timely  warning  or  of 
reassurance,  for  a  brief  consideration  of  the  affections  of  age,  even  though  we 
define  this  period  somewhat  loosely  and  with  apologies  for  the  lower  limit 
assumed,  as  one  beginning  some  years  after  the  menopause,  say  in  the  fifties, 
and  extending  to  the  close  of  life. 

Age,  as  we  shall  see,  gives  no  complete  immunity  from  gynecological  dis- 
eases, even  though  the  special  functions  of  the  organs  have  been  long  in  abey- 
ance. 

I  shall  consider  the  question  of  the  relation  of  age  to  these  special  diseases 
from  a  double  point  of  view :  First,  to  what  diseases  are  the  old  liable  ?  Sec- 
ondly, when  surgical  procedures  are  called  for,  do  the  old  bear  them  as  well  or 
worse  than  younger  women;  in  other  words,  is  age  any  contraindication  to  an 
operation  ? 

The  changes  occurring  in  age  are  characteristic.  They  begin  imperceptibly 
with  the  menopause,  but  do  not  become  strikingly  evident  for  many  years,  so 
slowly  do  they  advance.  The  chief  characteristic  is  an  atrophy  or  a  hypoplastic 
condition  of  the  organs  and  tissues.  The  uterus  becomes  as  small  as  that  of  a 
girl  before  puberty,  the  ovaries  are  sclerotic  and  contracted,  linear  or  beanlike 
fibrous  structures  containing  no  maturating  follicles,  the  uterine  tubes  are  also 
greatly  lessened  in  size  and  no  longer  trumpet-shaped.  The  external  genitals 
present  a  withered  appearance,  the  hair  becomes  gray,  the  labia  withered  and 
flaccid,  and  the  vaginal  outlet  is  smooth  and  inelastic,  while  the  vagina  also  has 
lost  its  rugse  and  is  converted  into  a  smooth  inelastic  tube. 

635 


636  DISEASES    OF    ADVANCED    AGE. 

The  following  conditions  call  for  consideration  in  advanced  age: 

( 1 )  Marriage. 

(2)  Pruritus. 

(3)  Cancer  of  the  clitoris  and  vulva. 

(4)  Vascular  tumors  of  the  urethra. 

(5)  Sensitive  vaginal  orifice,  and  atrophy  of  the  vagina. 

(6)  Vaginitis  with  or  without  occlusion  of  the   vagina. 

(7)  Cancer  of  neck  or  of  the  body  of  womb. 

(8)  Pyokolpos,  pyometra  and  physometra. 

(9)  Fibroid  uterine  tumors. 
(10)  Ovarian  tumors. 

(1)  Marriage. — A  first  marriage  in  a  woman  who  is  well  beyond  the  meno- 
pause is  usually  a  serious  mistake  if  her  husband  is  physically  vigorous.  Only 
a  complacent,  convenient  marriage  of  two  old  people  for  companionship  may 
entail  no  hardship  upon  the  wife,  who  is  unfitted  at  this  time  of  life  to  begin 
her  sexual  activities.  Let  the  woman  of  advanced  age  remain  single  if  she  will 
not  suffer  pain  and  humiliation. 

(2)  Pruritus  in  the  old  differs  in  no  way  from  that  in  younger  women,  ex- 
cept that  it  is  oftener  seen  in  an  aggTavated  form,  having  begun  at  an  earlier 
period  and  existed  longer.  These  cases  usually  call  for  surgery  to  extirpate 
the  disease,  sometimes  completely  removing  both  labia  and  the  clitoris.  Such 
operations  are  safe  and  well  borne,  the  age  of  the  patient  does  not  in  any  de- 
gree increase  the  risk. 

(3)  Cancer  of  the  clitoris  and  vulva  are  sometimes  found  in  the  old,  and  de- 
mand a  most  radical  operation,  including  the  extirpation  of  inguinal  glands  of 
the  affected  side.  Here,  too,  age  is  no  contraindication  to  the  most  exten- 
sive eradication  of  the  disease. 

(4)  Tumor  of  the  Urethra. — Vascular  tumors  are  occasionally  found  at  the 
external  urethral  orifice  in  women  past  the  menopause.  These  are  of  three 
kinds : 

(a)  More  or  less  from  infiltrated  rapidly  growing  ulcerated  excrescence,  a 
cancerous  growth,  sometimes  associated  with  cancer  in  the  adjacent  tissues. 

(&)  A  pedunculated  deep-red  sensitive  caruncle  which  has  no  particular 
relation  to  this  time  of  life. 

(c)  A  thickening  and  eversion  of  the  lips  of  the  urethra,  appearing  when 
closely  examined  like  a  prolajose  of  the  urethral  mucosa. 

I  think  that  in  the  case  of  any  marked  eversion  of  the  lips  of  the  urethra 
causing  discomfort  and  bleeding  readily,  the  physician  would  do  well  to  con- 
sult a  specialist  before  treating  the  cases  to  make  sure  they  are  not  malignant. 
In  the  moderate  eversions  presenting  red  pouting  lips,  the  best  treatment  is  a  two- 
per-cent  solution  of  silver  nitrate,  applied  every  other  day  on  a  cotton  pledget 
pressed  against  the  parts  and  held  there  for  t^\'enty  to  thirty  seconds.  Occa- 
sionally a  patient  can  be  taught  to  treat  herself,  and  this  is  better,  as  the  treat- 


VAGINITIS    OF    AN    ATROPHIC    CHARACTER.  637 

ment  may  have  to  be  kept  up  for  some  weeks  and  again  resmned  on  the  slight- 
est evidence  of  a  return  of  the  difBculty. 

(5)  Hypersensitive  Vaginal  Orifice  and  Atrophy  of  the  Vagina. — With  the  ex- 
treme involution  of  the  vagina  it  becomes  narrov^er  and  shorter  and  its  walls 
lose  all  traces  of  the  folds  and  corrugations  found  at  an  earlier  period.  The 
mucosa  becomes  pale  with  spots  here  and  there,  and  the  outlet  has  the  same 
smooth  appearance  with  perhaps  a  remnant  of  two  or  a  caruncle.  A  smooth 
outlet  with  spots  like  ecchymosis  is  often  sensitive,  and  a  source  of  much  dis- 
comfort in  the  marital  relation. 

I  know  of  no  other  way  of  treating  these  cases  than  the  application  of  that 
sovereign  remedy  for  inflamed  mucous  membrane,  silver  nitrate  in  a  three-  to 
five-per-cent  solution  on  alternate  days,  coupled,  with  the  advice  to  make  free 
use  of  a  lubricant  to  lessen  the  friction  in  the  sexual  approach. 

(6)  Vaginitis,  or  more  correctly  kolpitis,  of  an  atrophic  character  is,  perhaps, 
the  commonest  and  the  most  characteristic  of  the  genital  diseases  of  the  aged. 
It  is  rarely  met  with  before  the  menopause,  but  becomes  frequent  from  about 
the  age  of  fifty  upwards. 

The  patient  has  sensations  of  burning,  weight  and  bearing  down,  a  fullness 
in  the  pelvis,  which  is  soon  associated  with  a  slight  purulent  discharge,  some- 
times tinged  with  blood. 

The  blood  in  the  discharge  lends  great  importance  to  this  distressing,  but 
not  dangerous  malady,  as  it  is  for  this  reason  apt  to  be  mistaken  for  a  cancer 
by  the  general  practitioner.  Let  me  here  earnestly  remark  that  it  is  far  better 
to  err  in  this  safe  direction  than  to  commit  the  opposite  error ;  it  is  better  to 
think  that  every  suspicious  case  is  cancer  until  the  contrary  is  clearly  proved. 
Do  not  wait  until  the  diagnosis  is  made  certain  by  the  supervention  of  other 
symptoms. 

The  diagnosis  of  vaginitis  senilis  is  probable  when  a  patient  who  has 
had  a  slight  leucorrheal  discharge  notes  a  slight  bloody  stain  also  on  her  napkin. 
Examination  shows  the  usual  senile  changes  in  the  vagina,  while  the  vaginal 
vault  is  the  seat  of  the  most  marked  alterations. 

The  vault  is  narrower,  and  often  ends  in  a.  little  pocket  not  much  larger  than 
the  end  of  the  finger  or  thumb.  In  this  pocket  the  diminutive  cervix  may  be 
felt  with  difficulty.  Again,  a  striking  characteristic  of  a  case  may  be  one  or 
two  sharp-edged  falciform  folds  at  the  vaginal  vault,  shutting  off  a  pocket  above. 

The  best  way  to  examine  these  cases  is  in  the  knee^breast  position,  when  the 
vagina  distends  and  all  parts  can  be  well  seen  through  a  small  tubular  speculum 
with  a  stout  handle.  The  sharp  folds  stand  out  with  pockets  above  them,  and 
the  little  reddened  cervix  is  easily  distinguished. 

The  etiology  of  the  condition  appears  to  be  this :  the  parts  having  lost  their 
vitality  and  resisting  powers  are  easily  invaded  by  the  common  pyogenic  organ- 
isms, an  inflammation  is  set  up  with  ulceration,  and  destruction  of  the  super- 
ficial epithelium,  then,  either  healing  takes  place  with  the  formation  of  scar 
tissue,  which  on  shortening  forms  the  falciform  bands  felt,  or  agglutination  of 


638  DISEASES    OF    ADVANCED    AGE. 

opposed  inflamed  surfaces  occurs  with  a  corresjjondiug  narrowing  of  the  vagi- 
nal vault  This  process  is  then  but  a  simple  senile  vaginitis  carried  some  steps 
farther.  In  almost  every  instance  the  marked  anatomical  changes  take  place 
at  the  vaginal  vault,  where  the  secretions  natui'ally  stagnate. 

Treatment. — Douches  serve  well  to  keep  the  parts  clean,  but  have  no  per- 
manent curative  value.  A  warm  boric-acid  (5j  to  a  pint)  douche  may  be  given 
twice  a  day  to  remove  the  secretions.  The  curative  treatment  must  be  applied 
in  the  doctor's  ofiice. 

It  is  sometimes  a  strong  temptation  to  break  up  all  septa  and  separate  adher- 
ent surfaces  under  anestheti-c,  hoping  by  subsequent  packings  to  keep  up  the 
parts  separated  until  they  have  healed  again  in  their  normal  relationships. 

I  cannot  commend  this  plan  for  two  reasons — first  of  all,  the  trouble  in- 
variably gravitates  back  to  its  old  status,  and  in  the  second  place,  the  patient 
is  really  not  suffering  from  these  completed  changes,  but  from  the  underlying 
inflammatory  process  which  has  produced  them. 

The  treatment  must  then  be  directed  to  the  disease — ^to  destroying,  or  so 
far  inhibiting  the  activities  of  the  pus-producing  organisms  that  the  inflam- 
mation disappears. 

This  is  done  by  putting  the  patient  in  the  knee-breast  posture  and  introduc- 
ing a  cylindrical  speculum  as  large  as  she  can  comfortably  bear.  (See  Figs.  Y6A 
and  B.)  With  a  head  mirror  the  whole  vagina  is  inspected  and  all  secretions 
removed  with  pledgets  of  cotton;  then  take  a  cotton  applicator  and  saturate  it 
with  a  five-per-cent  solution  of  silver  nitrate,  and  swab  the  whole  vagina  thor- 
oughly with  this,  reaching  the  bottom  of  every  crevice  and  every  pit,  and  seeing 
that  the  application  reaches  all  parts,  as  the  speculum  is  withdrawn,  all  the 
way  down  to  and  including  the  external  oriflce.  There  may  be  some  disa- 
greeable aching  after  this,  so  it  is  well  to  keep  her  abed  for  a  few  hours  or  a 
day.  Xo  douches  are  to  be  taken  for  three  or  four  days.  As  soon  as  the  sil- 
ver-cauterized surface  epithelium  begins  to  come  off,  which  it  may  do  in  one 
piece,  douches  are  used  twice  a  day  until  another  application  is  to  be  made 
in  from  ten  days  to  two  weeks.  From  one  to  three  such  treatments  may  suf- 
fice to  cure  the  disease,  or  at  least  check  it  so  decidedly  that  it  is  no  longer 
annoying. 

(7)  Cancer  of  the  Womb. — Cancer  of  the  womb  occurs  frequently  in 
women  of  advanced  age.  In  Wertheim's  list  of  500  cases  of  cancer  of  the 
cervix  ("  Die  Erweiterte  Abdominale  Operation  bei  Carcinoma  Colli  Uteri," 
1911)  there  were  154  over  fifty  =  30.8  jDcr  cent,  showing  the  frequency  and 
importance  of  considering  both  the  liability  and  the  dangers  of  an  operation 
at  this  period. 

It  is  not  my  purpose  to  dwell  upon  this  subject  further  than  to  point  out 
that  the  disease  occurs  with  this  relative  frequency,  and  to  note  as  well  that 
age  constitutes  no  obstacle  whatever  to  a  radical  operation  for  its  relief.  In- 
deed the  disease  often  advances  more  slowly  and  is  less  malignant  in  the  aged 
than  in  the  young. 


PYOKOLPOS,    PYOMETEA    AND    PIIYSOMETRA. 


639 


(8)  Pyokolpos,  Pyometra  and  Physometra. — These  conditions  are  marked 
bj  an  accumulation  of  pus  in  the  vagina,  and  in  the  uterus,  or  by  air  in  the 
uterus.  They  are  closely  allied  conditions  due  to  an  occlusion  in  the  genital 
tract  with  an  accumulation  of  secretions  above  it. 

Pyokolpos  is  rare,  I  have  seen  but  one  case,  that  figured  in  the  text.  The 
patient,  fifty-seven  years  old,  had  had  some  operation  for  atresia  about 
puberty.  She  then  menstruated  normally  all 
her  life,  remained  unmarried,  and  passed 
through  a  natural  menopause  at  forty-five. 
Twelve  years  later  she  came  to  me  complain- 
ing intensely  of  her  bladder.  I  found  an 
atresia  of  the  vagina  (see  Fig.  164)  about  an 
inch  inside,  and  above  this  a  large  fluctuating 
tumor,  on  top  of  which  the  body  of  the  uterus 
sat  like  a  cap,  well  below  the  umbilicus.  Some 
hard  nodules  felt  by  rectum  justified  the  di- 
agnosis of  atresia  of  the  vagina,  with  a  large 
pyokolpos  due  to  cancer  of  the  womb  and 
vagina.  I  opened  the  narrow  bridge  of  the 
atresia  by  a  careful  dissection  between  rec- 
tum and  vagina,  and  let  out  about  500  c.c. 
of  pus  from  the  vagina,  and  then  by  pres- 
sure emptied  about  50  c.c.  from  the  uterus 
itself;  the  cervix  and  vagina  were  found  to 
be  the  seat  of  an  extensive  cancerous  growth. 

Pyometra  is  a  commoner  affection  and  is 
one  of  the  truly  characteristic  diseases  of  the 
old  (the  other  being  occlusive  vaginitis).  It 
arises  from  an  occlusion  of  the  cervix,  due  to 
a  disease  associated  with  a  discharge  of  an  infectious  nature;  that  is  to  say, 
either  an  endocervicitis  or  a  cancer  of  the  cervix. 

Let  me  speak  first  of  the  latter.  Oftentimes  a  patient,  especially  an  elderly 
woman,  has  a  slow  growing  cancer  which  chokes  the  cervix  and  dams  up  any 
uterine  secretions,  and  these  of  the  tumor  above  until  the  uterus  becomes  a 
thinned-out  distended  sac  full  of  pus,  or,  if  gases,  too,  are  formed,  of  pu.s  and 
air  (pyo-physometra). 

These  patients  suffer  from  much  lower  abdominal  tenderness,  which  the 
physician  is  too  apt  to  attribute  to  the  obvious  cancer,  they  are  relieved  as 
soon  as  the  cancer  is  scraped  away,  affording  a  free  exit  to  the  pus  pent  up  in 
the  womb.  It  behooves  the  doctor,  therefore,  always  to  be  alert  in  his  cancer 
cases,  looking  for  such  accumulations  in  cancer  patients  who  complain  of 
much  pain. 

Again,  when  a  simple  endocervicitis  occludes  the  neck  the  result  is  the 
same;  in  time  a  painful,  purulent  accumulation  forms,  and  this,  unless  he  is 


Fig.  164. — Pyokolpos  and  Pyometra 
DUE  TO  Complete  Stricture  of  the 
Vagina. 


640 


DISEASES    OF    ^IDTAXCED    AGE, 


miicli  on  liis  guard,  the  attending  physician  will  mistake  for  a  simple  cervi- 
citis and  vaginitis.  He  mnst  look  with  more  than  suspicion  on  every  elderlv 
woman  who  Tias  a  fetid  leucon*hea,  w^hich  varies  considerably  in  amount  and 
is  associated  with  tormenting  pains  at  intervals.     The  first  step  is  to  dilate 

the  cervical  canal  and  to  make 
sure  by  curettage  that  there  is 
no  cancer  developing  inside  the 
cervical  canal  or  in  the  uterine 
body.  After  this  evacuation  a 
free  exit  must  be  maintained  by 
using  cervical  dilators,  and  there 
are  none  better  than  Hegar's 
graduated  series.  It  is  not  nec- 
essary to  expand  the  canal  more 
than  10-12  mm.  in  diameter, 
and  this  is  better  done  with 
these  instruments  than  with  the 
usual  branched  dilators,  which 
are  more  liable  to  rupture  the 
friable  tissues. 

After     dilating    the     cervix: 

and   emptying   the   uterine   sac, 

then     apply    thoroughly    on     a 

pledget  of  cotton,  or  on  a  strip 

of  gauze,  with  a  string  attached, 

a  solution  of  formalin,   1 :  2,000,  to  be  left  in  situ  for  half  an  hour.      This 

should  be  done  every  three  or  four  days  until  the  infection  clears  up  and  the 

secretion  from  the  uterus  looks  like  simple  mucus. 

(9)  Fibroid  Tumors. — Two  things  should  be  known  about  fibroid  tumors, 
rirst,  that  they  do  occur  with  considerable  frequency  in  the  old.  Out  of  1,307 
cases  reported  upon  by  T.  S.  Cullen  and  myself,  there  were  196  between 
forty-six  and  fifty  years  of  age  :^  to  fifteen  per  cent ;  there  were  101 
cases  between  fifty-one  and  sixty  years  =  7.7  per  cent,  and  there  were  13 
over  sixty-one  years.  The  second  fact  of  importance  is  to  be  able  to  assure 
any  patient  in  advanced  years,  approaching  such  an  operation,  that  age  alone 
has  no  appreciable  effect  upon  the  outcome  of  an  operation.  Fibroid  tumors 
do  not  call  for  operation  unless  they  are  doing  some  harm.  A  tumor  choking 
the  pelvis  or  a  larger  tumor  making  serious  or  distressing  pressure  on  the 
abdominal  viscera,  or  a  tumor  complicated  by  lateral  inflammatory  disease 
calls  for  operation. 

(10)  Ovarian  Tumors. — The  ovaries  begin  to  atrophy  with  the  menopause, 
and  so  confer  a  relative  immunity  to  tumors  of  these  organs.  Still,  ovarian 
tumors  have  been  observed,  and  the  dread  in  an  elderly  woman  of  such  an 
operation  is  apt  to  be  so  great  that  it  becomes  a  matter  of  importance  to  in- 


FiG.  165. — Hegar  Dilators.  Very  valuable  in  slow  dila- 
tions of  the  cer\'ix  uteri  for  dysmenorrhea,  also  in  dilat- 
ing the  urethra. 


OVAEIAKT    TUMORS. 


641 


quire  how  frequently  these  cases  are  seen,  and  what  are  the  statistics  of  oper- 
ations for  their  relief.  Bland-Sutton  ("  Surgical  Diseases  of  the  Ovaries  and 
Fallopian  Tubes  ")  inquired  into  this  subject  in  the  late  eighties,  and  in  the 
early  nineties  I  investigated  it  with  Dr.  Mary  Sherwood,  collecting  in  all  "  100 
cases  of  ovariotomy  performed  in  women  over  seventy  years  of  age."  We  found 
that  although  a  number  of  the  cases  dated  back  to  the  early  ovariotomy  days, 
and  many  operators  w^ere  concerned,  yet  the  surprisingly  low  mortality  of 
twelve  per  cent  prevailed.  Thirty  of  the  cases  were  over  seventy-four  years, 
and  only  two  of  these  died.  There  were  only  two  dermoid  cysts.  About  40 
cases  in  this  creditable  list  are  to  be  set  to  the  account  of  our  countrymen. 

For  the  encouragement  of  any  thus  afflicted  I  append  a  list  of  all  the 
cases  of  eighty  years  and  over  I  have  been  able  to  find.  (See  "  Surgical  Dis- 
eases of  the  Ovaries,"  1896.     Bland-Sutton.) 


Schroeder 

Pippingskold .  .  . 

Owens 

Richardson .... 
Heywood  Smith . 

Homans 

Spencer 

Edis. 

Bush 

Remfrey 

Kraft 

Owens  * 

Thornton 

Cartledge 


80 

R. 

80 

R. 

80 

R. 

80 

R. 

81 

R. 

82 

R. 

82 

R. 

81 

R. 

84 

R. 

83 

R. 

84 

R. 

87 

R. 

94 

R. 

803^ 

R. 

"  Krankheiten  d.  Weibl.  Geschl." 

"Finska  Laken  Handlingen,"  Helsingfors,  1884. 

J.  Brit.  Gyn.  Soc,  iv.,  p.  88. 

Brit.  M.  J.,  1891,  i.,  p.  523. 

Lancet,  1894,  i.,  p.  1618. 

Bost.  M.  and  S.  J.,  1888,  p.  454. 

Brit.  M.  J.,  1893,  ii.,  p.  1271. 

Brit.  M.  J.,  1892,  i.,  p.  860. 

Brit.  M.  J.,  1894,  ii.,  p.  67. 

Tr.  Obstet.  Soc.  London,  xxxvii,  p.  152. 

Hospitalstidende,  Copenhagen. 

Lancet,  1895,  i.,  p.  542. 

Tr.  Obstet.  Soc.  London,  xxxvii.,  p.  158. 

South.  Sur.  and  Gyn.  Trans.,  1896,  p.  153. 


*  A  second  operation  on  third  patient  on  this  list. 

The  first  two  cases  are  added  from  a  nearly  similar  list  given  by  Leonard 
Eemfrey  in  the  Trans,  of  the  Obstet.  Soc.  of  London,  1895,  p.  158.  The  last 
one  was  operated  upon  by  Morgan  Cartledge  and  is  recorded  in  the  South. 
Sur.  and  Gyn.  Trans.,  1896,  p.  153. 

Spencer  Wells  ("  Ovarian  and  Uterine  Tumors,"  1882,  p.  256)  remarks: 
"  Dr.  Ogle  writes  to  me  that  in  deaths  due  to  ovarian  dropsy  or  ovariotomy 
during  the  past  ten  years,  seven  were  of  women  over  eighty-five  years  of  age." 
This  is  evidently  from  the  public  health  records  of  Great  Britain. 

Leon  Peaudeleau  {Marseilles  medical,  1903,  p.  756)  records  a  case  of  an 
ovarian  cyst  found  post  mortem  in  a  woman  of  eighty-two. 


42 


INDEX 


Abdomen,  chain  of  organs  on  right  side 
of,  28. 
examination  of,  6. 
Abdominal  operation.     See  operation. 
Abel,    Mrs.    Mary   Hinman,    on   training 

young  girls  for  home  life,  42. 
Aberle,   on  hysteria  and  floating  kidney, 

597. 
Abortion,  452. 

artificial,  303,  473. 
complications  of,  460. 
criminal,   473. 
definition  of,  452. 
etiology  of,  454. 
frequency  of,  452, 
history  of,  452. 
incomplete,  165. 
mechanism  of,  457. 
"  missed,"  454. 
prognosis  of,  460. 
septic,  470. 

symptoms  and  diagnosis  of,  458. 
threatened,  165. 
treatment  of,  460. 
Acetanilid,  use  of,  in  treatment  of  head- 
ache, 235. 
Acetone  in  treatment  of  inoperable  can- 
cer, 539. 
Acne,  facial,  associated  with  constipation, 

207. 
Acromegaly,  association  of,  with  amenor- 
rhea, 148. 
Addison's  disease,  diagnosis  between,  and 

pigmentary  syphilide,  413. 
Adenitis,  gonorrheal,  385. 
Adenoids  in  school-girls,  57. 
Adenoma,  diagnosis  of,  501. 
Adenomyomata,  489. 

Adnexa,  uterine,  disease  of,  and  appendi- 
citis, 586,  587,  589. 
associated  with  infected  fibroids,  497. 


Adnexa,  uterine,  disease  of,  cause  of  abor- 
tion, 456. 
cause  of  sterility,  365. 
removal  of,  for  dysmenorrhea  unjus- 
tifiable, 126. 
for  intermenstrual  pain,  137. 
Adrenalin    in    uterine    hemorrhage,    185, 

206,  542. 
Air,  pure,  essential  to  public  health,  44. 
Albarran,  on  tubercular  infection  of  blad- 
der, followed  by  other  infections, 
558. 
Alberts,  case  of  smallpox  followed  by  atre- 
sia of  genital  tract,  266. 
Albumen,  presence  of,  in  cystitis,  549. 
in  Dietl's  crisis,  589,  611,  613. 
in  pyelitis,  548,  549. 
in  syphilis,  426. 
Albuminoids,  reduction   of,  in  treatment 

of  obesity,  246. 
Alcohol,  effects  of,  on  headache,  227. 
on  menstrual  flow,  149. 
on  syphilis,  396,  441. 
percen+age  of,  in  patent  medicines,  114. 
Alcoholism  a  cause  of  abortion,  454,  456. 
of  amenorrhea,  149. 
of  sterility,  367. 
Alimentary  system,  syphilis  of,  421. 
Aloes,  as  an  emmenagogue,  160. 

in  constipation,  220,  603. 
Aloin,  220. 
Alopecia,  420. 

Alum  in  vaginal  douche,  248. 
Amann,    on    isolation    of    gonococcus    in 
blood  current,  378. 
on  production  of  gonorrhea,  379. 
Amenorrhea,  140. 
blood  in,  163. 
constitutional,  145, 
definition  of,  140. 
from  imperforate  hymen,  151, 
643 


644 


IK"DEX. 


Amenorrliea,   from   maldevelopment.   140, 
177. 
fuuctional,  149,  159,  367. 
in  acute  diseases,  148. 
in  atresia  of  genital  tract,  142,  151,  153. 
in  clilorosis,  146,  155. 
in  chronic  diseases,  148,  159. 
in  obesity,  148,  245. 
in  super-involution  of  uterus,  160. 
in  tuberculosis,  148. 
mecbanical,  145. 
physiological,   145. 
priraary,  140. 
secondary,  140,  145. 
symptoms  and  diagnosis  of,  150. 
treatment  of,  153. 
Ammonia,  aromatic  spirits  of,  with  coal- 
tars,  114,  235. 
chloride   of,   in  treatment   of   infantile 

syphilis,  443. 
output  of,  in  relation  to  total  nitrogen 
excretion,  474. 
Amnion,   imperfect  vascularization   of,   a 

cause  of  abortion,  454. 
Amyloid    degeneration    of    fibroid    polyp, 

496. 
Anaphrodisia  a  cause  of  sterility,  367. 
Anatomical  causes  of  sterility  in  female, 

357. 
Anchylosis,  relation  between,   and  coccy- 

godynia,  262. 
Anders,  on  diet  in  obesity,  247. 

on  heredity  as  cause  of  obesity,  208. 
Anemia  associated  with  amenorrhea,  148. 
with  dysmenorrhea,  109. 
with  fibroid  tumor,  498,  504. 
with  headache,  225,  233. 
with  obesity,  244. 
Anesthesia,    chloroform,    in    examination 
of  fjelvic  organs  in  child,  26. 
in  protection  of  perineum,  484. 
general,  in  examination  of  bladder,  563. 
in  examination  of  pelvic  organs,  26. 
in  mechanical  evacuation  of  the  ute- 
rus, 468. 
in  pruritus,  301. 
in  vaginismus,  307,  308. 
local,  in  excision  of  piece  of  cervix,  526. 
in  incision  of  abscess  of  Bartholin's 
gland,  278. 


Anesthesia,  local,  in  removal  of  urethral 
caruncle,  307. 
nitrous  oxide  gas,  in  diagnosis  of  retro- 
displacements,  323. 
in  dilatation  of  cervix,  123. 
in  fissure  of  rectmn,  38. 
in  gynecological  examination,  27. 
Anesthesin  in  treatment  of  pruritus,  300. 
Angina  pectoris  due  to  syphilis,  425. 
An  sell,  on  interval  between  marriage  and 

birth  of  first  child,  350. 
Anteflexion  of  uterus.     See  Uterus. 
Antisepsis,    intestinal,    in    treatment    of 

chlorosis,  157. 
Antitoxin  in  diphtheritic  vaginitis,  281. 
Anton,  on  statistics  of  hereditary  syphilis, 

432. 
Anus,  fissures  of,  a  cause  of  masturbation, 

310. 
Apartment  houses,  effect  of,  on  health  of 

child,  48. 
Apenta  water  in  constipation,  221. 
Aphthae,  diagnosis  between,   and  syphilis 

of  oro-pharyngeal  cavity,  421. 
Apiol,  as  an  emmenagogue,  160. 

in  menorrhagia,  185. 
Aplasia  of  reproductive  organs  a  cause  of 

amenorrhea,  140,  150. 
Apostoli,  on  galvanic  current  in  treatment 

of  amenorrhea,  155,  507. 
Appendicitis,  association  of,  with  pelvic 
disease,  587. 
cause  of  abortion,  455. 
diagnosis  between,  and  pelvic   disease, 

589. 
dysmenorrhea  associated  with,  592. 
in  child,  595. 
independent    coexistent    pelvic    disease 

and,  589. 
relation     between,     and     extra-uterine 
pregnancy,  589. 
and  movable  kidney,   552. 
simulation  of,  by  movable  kidney,  611, 
612. 
Appendix  vermif ormis,  examination  of,  9. 
Aristol    in   treatment    of    nasal    syphilis, 

442. 
Arnal,  on  uterine  hemorrhage  fromi  calci- 
fication of  uterine'  blood-vessels, 
178. 


INDEX. 


645 


Arnold,  case  of  atresia  of  genital  tract 

following  dysentery,  266. 
Arseniate  waters  in  treatment  of  chloro- 
sis, 157. 
Arsenic,    hypodermic    administration    of, 
157. 
in  chlorosis,  157. 
in  chorea,  158. 
in  headache,  233. 
in  obesity,  245. 

in  pelvic  disease  associated  with  mala- 
ria, 272. 
in  pruritus,  299. 
in  splanchnoptosis,  603. 
manganese  and,  157. 
Arsenious  acid  in  cancer  of  uterus,  538. 
in  chorea,  157. 

in  pelvic  disease  associated  with  mala- 
ria, 272. 
Arterial  tension,  increase  of,  a  cause  of 

headache,  226,  233. 
Arterio-sclerosis  in  syphilis,  397. 
Arteritis  in  syphilis,  425. 
Arthritis,  gonorrheal,  377,  381,  385. 

syphilitic,  428. 
Asafcetida,    in    treatment    of    threatened 
abortion,  462. 
in  treatment  of  constipation,  222. 
milk  of,  as  enema,  222. 
Ascarides,  a  cause  of  appendicitis  in  chil- 
dren, 595. 
a  cause  of  pruritus,  296,  298. 
Ascites,  complicating  fibroid  tumors,  500. 
relief   of,   followed  by  splanchnoptosis, 
599. 
Asepsis,  in  dilatation  of  cervix,  122,  373. 
in  gynecological  examination,  6. 
in    mechanical    evacuation    of    uterus, 

467,  469. 
in    operation    for    imperforate    hymen, 

154. 
in  treatment  of  chancre,  404. 
in   use   of   intra-uterine  tampons,   466, 

509. 
in  use  of  obstetrical  forceps,  482. 
Ashton,    on    age    of    first    menstruation, 
82. 
on  duration  of  menstrual  period,  84. 
Ashwell,  on  treatment  of  pruritus  in  preg- 
nancy, 303. 


Aspirin  in  cancer,  541. 
in  insomnia,  242. 
in  lumbago,  250. 
in  rheumatic  headache,  234. 
Asymmetry  in  young  girls,  63. 
Athletic  fields  for  girls,  61. 
Athletics,  interschool  and  intercollegiate, 
68. 
outdoor,  for  school  girl,  61. 
Atresia  of  cervix,  145,  146. 

of   genital   tract,    a    cause    of    primary 

amenorrhea,  140. 
due  to  infectious  diseases,  142,  265. 
to  cholera,  267. 
to  diphtheria,  267. 
to  dysentery,  266. 
to  erysipelas,  267. 
to  measles,  267. 
to  pneumonia,   267. 
to  scarlatina,  143,  266,  267. 
to  smallpox,   266. 
to  typhoid  fever,  143,  266. 
in  infants,  144. 
necessity  for  operation  in,  153. 
Atresia  of  uterine  tubes  causing  sterility, 

358,  365. 
Atresia  of  vagina,  congenital,  142. 
due  to  difficult  labor,  145. 

to  infectious  diseases,  142,  265,  479. 
to  pessaries,  145. 
to  trauma,  146. 
Atrophy  of  uterus,  cause  of  sterility,  366. 

in  acromegaly,  148. 
Australia,   age   of   first   menstruation   in, 

83. 
Auto-intoxication,  cause  of  headache,  227. 
Ayer's  Sarsaparilla,  percentage  of  alcohol 

in,  114. 
Azoosperraia,  causes  of,  352. 
prognosis  of,  353,  369. 

Backache,  250. 
character  of,  251. 
etiology  of,  251. 
formulae  for  relief  of,  256. 
frequency  of,  250. 
from  constipation,  208. 
from  sacro-iliae  affections.     See  Sacro- 
iliac joints, 
locations  of,  250. 


646 


INDEX. 


Backache,  massage  for,  256. 
post-operative,  251,  260. 
prophylaxis  of,  250. 
treatment  of,  256. 
Bainbridge,  on  etiology  of  cancer,  514. 
Balano-preputial  furrow,  chancre  on,  400. 
Baldy,  W.  H.,  on  amenorrhea  caused  by 

uric  acid  diathesis,  149. 
Ball,  metal,  in  treatment  of  constipation, 

221. 
Bandage,    abdominal,    in   acute   lumbago, 
250. 
in  movable  kidney,  618. 
in  splanchnoptosis,  603. 
necessity  for,  after  abdominal  opera- 
tions,  602. 
Glenard's  elastic,  603. 
Bandaging,  in  anemia,  206. 
in  phlebitis,  631. 

Rose's   method   of,    in   splanchnoptosis, 
603. 
Banting's    method    of    reducing    obesity, 

248. 
Bar,  on  abortion,  454. 
Barbour,  on  hemorrhage  from  sclerosis  of 

uterine  blood-vessels,  177. 
Barnes,    K.,    on    vicarious    menstruation, 

160. 
Barthelemy  on  case  of  smallpox  followed 

by  atresia  of  genital  tract,  266. 
Bartholinitis,  276. 

Bartholin's  glands,  abscess  of,  276,  278. 
cyst  of,  276,  277. 
examination  of,  19. 
excision  of,  277. 
infection  of,  after  labor,  480. 
cause  of  sterility,  358,  359. 
in  gonorrhea,  380. 
in  vulvitis,  276,  277. 
susceptibility    of,   to   gonorrheal    infec- 
tion, 380. 
Basedow's  disease,  amenorrhea  in,  148. 
Bashford,  on  malignant  tumors,  516. 
Baths,  cold,  in  menstruation,  72. 
in  treatment  of  headache,  231. 
in  treatment  of  pri;ritus,  263. 
hot,  in  amenorrhea,  160. 
in  dysmenorrhea,  116. 
in  headache,  231. 
in  insomnia,  240, 


Baths,  hot,  in  inenstruation,  72. 
in  pruritus,  263,  301. 
mustard,  116,  231. 
Beard,    on    "phobias,"    569. 
on  trypsin  in  cancer,  539. 
Beigel,  on  coccygodynia  in  child,  261. 
Belt-test,  601. 

Bernutz  and  Goupil,  on  gonorrhea  in  cau- 
sation of.  pelvic  peritonitis,  375. 
Bertillon,  table  by,  on  annual  birth  rate, 

348. 
Bichloride  of  mercury.     See  Mercury. 
Binkley,   on  appendicitis  and  pelvic  dis- 
ease, 586. 
Bismuth  subnitrate,  emulsion  of,  for  X- 
ray  examination  of  stomach,  601. 
powder     for     gonorrheal     infection     in 
child,  391. 
Black  wash,  in  treatment  of  chancre,  404. 
Bladder,  examination  of.     See  Cystitis, 
gonorrheal  infection  of,  376,  378,  386. 
inflammation  of.     See  Cystitis, 
palpation  of,  by  vagina,  13. 
syphilis  of,  426. 
Blaud's  pills,  formula  for,  156. 
Blood,  alterations  in,  a  cause  of  pruritus, 
295. 
in  chlorosis,  146,  153. 
in  pelvic  disease  associated  with  ma- 
laria, 272. 
in  syphilis,  394,  395,  398. 
changes  in  specific  gravity  of,  in  chlo- 
rosis, 146. 
in  obesity,  244. 
Blood-letting,  general,  in  headache,  231. 

local,  161. 
Blood-vessels,  changes  in,  during  syphilis, 

397,  425. 
Boaz,  on  increase  of  height  in  young  girls, 

65. 
Boehm,  on  case  of  atresia  of  genital  tract 

following  typhoid  fever,  266. 
Boldt,  H.  J.,  on  cervical  cancer  in  nulli- 
parae, 517. 
on    fibroid    tumors    and    heart    disease, 

505. 
on  methylene  blue  in  treatment  of  in- 
operable cancer,  537. 
on    stypticin    in    treatment    of    uterine 
hemorrhage,  508. 


INDEX. 


647 


Bone,  excision  of  spicule  of,  for  relief  of 

headache,  234. 
Bones,  syphilis  of,  427. 
Boroglycerid,  action  of,  324. 
packs  in  vaginitis,  285. 
suppositories  in  gonorrhea,  389. 
Bougies  in  treatment  of  vaginismus,  308. 
of  iodoform,  in  chancre  of  meatus  uri- 
narius,  404. 
Bourgeois,  on  case  of  erysipelas  followed 

by  atresia  of  genital  tract,  267. 
Bowels,   care   of,   after   abdominal   opera- 
tions, 222. 
before  abdominal  operations,  221. 
during  prolonged  convalescence,  628. 
evacuation  of,  hindered  by  tight  corset, 
213. 
importance  of  daily  habit  in,  31,  53, 

212. 
influence  of  diet  on,  209. 
proper  posture  in,  210. 
Brace,  steel  spring,  in  treatment  of  sacro- 
iliac joint  relaxation,  259. 
Bradford  frame  in  appendicitis  in  child, 

596. 
Brain,  disease  of,  cause  of  headache,  226. 
indication  for  abortion,  474. 
in  syphilis,  428,  430,  431. 
Brandes,  on  abortive  treatment  of  chan- 
cre, 404. 
Bright's     disease,     arterial     tension     in- 
creased in,  226. 
artificial  abortion  in,  474. 
headache  in,  225,  226. 
migraine  in,  237. 
syphilis  a  factor  in,  426. 
Bromide  of  potash.     See  Potassium. 
Bromide  of  sodiiin:i.     See  Sodium. 
Bromides  in  gonorrhea,  386. 
in  headache,  158,  233,  234. 
in  insomnia,   243. 
Bronchi,  syphilis  of,  423. 
Brose,  case  of  atresia  of  genital  tract  fol- 
lowing pneumonia,  267. 
on    galvano-faradism    in    treatment    of 
constipation,  218. 
Brown  atrophy  of  heart,  504. 
Brunton,  Lauder,  formula  of,  for  relief  of 

rheumatic  headache,  234. 
Bubo,  345,  402. 


Bumm,  E.,  description  of  gonococcus  by, 
377. 
on  the  causes  of  sterility,  351. 
on  the  gonococcus  in  squamous  epithe- 
lium, 378. 
Burnam,   C.  F.,   on  cervical  cancer  in  a 

nullipara,  517. 
Burrage,  W.   L.,   on  anatomy  of  meatus 
urinarius,  380. 
on  electricity  in  treatment  of  fibroids, 

459. 
on  heart  disease  and  fibroids,  504. 
on  helonias  compounds,  115. 
on  leeches  applied  to  cervix  for  amenor- 
rhea, 145. 
Bursae,  syphilis  of,  427. 

Cabot,  on  hematuria  associated  with  mov- 
able kidney,  613. 
Cachexia,  cancerous,  518. 
Caffein  in  treatment  of  headache,  235. 
Calcification  of  fibroid  tumor,  495. 

of  uterine  blood-vessels,  a  cause  of  hem- 
orrhage, 178. 
Calcium  chloride  in  treatment  of  uterine 

hemorrhage,  185. 
Calcium  lactate  in  treatment  of  dysmen- 
orrhea, 117. 
Calibration  of  vaginal  outlet,  479. 
Calmann,    on    necessity    for    cultures    of 

gonococcus,  385. 
Calomel,  hypodermic  injection  of,  439. 
in  chancre,  404. 
in  constipation,  157,  220,  222. 
in  gonorrhea  and  syphilis  in  child,  391. 
in  headache,  229. 
in  infantile  syphilis,  443. 
in  migraine,  200. 
in  syphilis,  439,  442. 
in  torpidity  of  liver,  222. 
in  vomiting,  158. 
von   Campe,   H.,   on  galvanic  current  in 

pruritus,  302. 
Camphor  in  treatment  of  vaginitis,  285. 
Camp-life  in  treatment  of  insomnia,  241. 
Cancer  of  cervix,  age  when  most  frequent, 
169,  517. 
curability  of,  520. 
diagnosis  of,  520. 
exertion  cause  of  hemorrhage  in,  518. 


648 


INDEX. 


Cancer  of  cervix,  local  signs  of,  170,  520. 

microscopical  signs  of,  170,  527. 

progress  of,  520. 

relative  proportion  of,  to  cancer  of  fun- 
dus, 517. 

trauma  in  causation  of,  516. 
Cancer  of  fundus,  curability  of,  520. 

curettage  for  purposes  of  diagnosis  in, 
170,   526.    . 

local  signs  of,  170,  525. 

microscopical  signs  of,  527. 
Cancer  of  intestines,  removal  of  piece  of, 

for  examination,  38. 
Cancer  of  pelvis  complicating  fibroid  tu- 
mors, 500. 
Cancer  of  rectum,  diagnosis  between,  and 

pelvic  tumor,  3-1. 
Cancer  of  uterus,  513. 

acetone  in  treatment  of,  539. 

age  at  whicli  most  frequent,  170,  517. 

association  of,  with  fibroid  tumors,  496. 

cachexia  in,  169,  518. 

cauterization  in,  536. 

clinical  history  of,  517. 

congenital  transmission  of,  517. 

contagion  of,  514. 

curability  of,  520,  531,  532. 

diagnosis  of,  517. 

disinfection  in,  516,  542,  633. 

duty  of  physician  in,  516,  520,  530,  533, 
542. 

education  of  public  in  regard  to,  519, 
530. 

emaciation  in,  169,  519. 

endometrium  in,  changes  of,  527,  528. 

etiology  of,  513. 

examination  of  pelvic  organs  in,  520. 

extension  of,  to  other  organs,  508,  534. 

hemorrhage  in,  169,  518,  519,  542. 

heredity  in  causation  of,  515,  516. 

hygienic  measures  in,  541. 

importance  of   early  diagnosis  in,  169, 
519,  530,  533. 

in  old  age,  638. 

infection   in,   515. 

local  signs  of,  520. 

menstruation  in,  169,  517. 

methylene  blue  in  treatment  of,  537. 

microscopic  sigTis  of,  525. 

operation  for,  532,   533. 


Cancer  of  uterus,  opium  in  treatment  of, 
538,  541,  634. 
pain  in,  169,  170,  518,  519. 
palliative  treatment  of,  533. 
progress  of,  170,  522. 
prophylaxis  of,  630. 
pruritus   caused  by,   396. 
pyometra   in,   533,   534. 
radium  in  treatment  of,  537. 
trypsin  in  treatment  of,  539. 
thyroid  extract  in  treatment  of,  539. 
vaginal    discharge    in,    169,    170,    518, 

519. 
varieties  of,  520. 
X-ray  in  treatment  of,  537. 
Cannabis   indica,   in   treatment    of   head- 
ache, 234. 
in  treatment  of  imminent  abortion,  462. 
Capillary  dilatation  a  cause  of  insomnia, 

238. 
Capsicum  in  constipation,  220. 
Carbolic  acid  douche  in  infectious  disease, 

271. 
Carbolic    acid    internally    for    vomiting, 

158. 
Carbolic   acid  locally  in   abscess   of  Bar- 
tholin's gland,  278. 
in  cancer  of  cervix,  536. 
in  membranous  dysmenorrhea,  to  uter- 
ine cavity,  131  . 
Carbolic  acid  lotion  in  treatment  of  pru- 
ritus,  298,   300. 
Carbolic  acid  poultice  in  pruritus,  301. 
Carbonic  acid  gas,  inflation  of  stomach  by, 
601. 
treatment  of  gonorrhea  by,  in  nascent 
state,  388. 
Carcinoma.     See  Cancer. 
Carlsbad,  treatment  of  obesity  at,  246. 
Carlsbad  salts,  221,  231,  462. 
Carpenter,  J.  G.,  on  examination  of  rec- 
tum,  34. 
Carriage,  faulty,  in  young  girls,  63. 
Caruncle,  urethral,  associated  with  vagi- 
nismus, 306,  307. 
Cascara  in  chronic  constipation,  219. 
in    post-operative     convalescence,     222, 

625. 
in  rest  cure,  580. 
in  splanchnoptosis,  555. 


INDEX. 


649 


Casper,  on  prostatitis  in  connection  with 

urethritis,  362. 
Catheter,  Dickinson's  two-way,  560. 
indications  for  use  of,  in  labor,  486. 
injury  from,  386,  544,  555. 
method  of  using,  556. 
self-retaining,  564. 

wax-tipped,   in  diagnosis  of  renal  cal- 
culus, 29,  616. 
Cautery,  actual,  in  carcinoma  of  uterus, 
536. 
in  cervicitis,  288. 
in  endometritis,  294. 
in  fibroid  tumors,  509. 
Celsus,  on  abortion,  452. 
Cervicitis.     See  Endocervicitis. 
Cervix  uteri,  atresia  of.     See  Atresia. 
cancer  of.     See  Cancer. 
chancre  of,  400. 

elongation  of,  a  cause  of  sterility,  361. 
erosion    of,    associated   with    intermen- 
strual pain,  136,  137. 
cause  of  sterility,  361. 
mistaken  for  cancer,  525. 
real  nature  of,  21. 
excision  of  a  piece  of,  525. 
expulsion  of  ovum  into,  457. 
fistula  of,  478. 
gonorrheal   infection    of,    the   cause   of 

sterility,  287,  361,  374. 
gradual  dilatation  of,  dangers  of,  122. 
in  artificial  abortion,  469,  475. 
in  labor,  482. 
incision  of  anterior  wall  of,  501. 
infection  of,  after  labor,  480,  486. 

signs   of,   20. 
injury  to,  a  cause  of  abortion,  456. 
inspection  of,  20. 
laceration  of,  after  labor,  478. 
associated  with  abortion,  461. 
cause  of  backache,  256. 
cause  of  sterility,  362. 
operation  for  repair  of,  32,  486. 
leucorrhea  from,  20,  287. 
plaque-like  areas  of,  mistaken  for  can- 
cer, 525. 
position  of,  in  vaginal  examination,  11. 
rapid  dilatation  of,  123. 
after-treatment  of,  126. 
cases  suited  to,  121. 


Cervix  uteri,  rapid  dilatation  of,  dangers 
of,   125,  353. 

for  dysmenorrhea,  121. 

for  intermenstrual  pain,  136. 

for  pruritus,  299. 

for  sterility,  371. 

for  vaginismus,  307. 

in  abortion,  469. 

in  labor,  482. 

instruments  for,   123. 

method  of,  123. 

preliminaries  to,  122. 
repair  of,  following  laceration  in  labor, 

486. 
scarification  of,  for  suppressed  menstru- 
ation, 159,  162. 
stenosis   of,    a   cause    of   sterility,    358, 
361,  373. 

associated  with  dysmenorrhea,  107. 
susceptibility  of,  to  infection,  380,  517. 
ulceration  of,  mistaken  for  cancer,  518. 
"  weeping,"  287. 
Chancre,  399. 

abortive  treatment  of,  404,  437. 

diagnosis  of,  402. 

differential     diagnosis     between,     and 

chancroid,  403. 
digital,  401,  404. 
extra-genital,  401,  403. 
ex-ulcerative,  400. 
herpetiform,  400,  403. 
Hunterian,  400. 
in  female,  400. 
incubation  period  of,  399. 
induration  of,  399. 
labial,  401. 
mixed,  400. 
multiple,  400. 
nasal,  401. 
of  eyelid,   401. 
of  face,  401. 
of  nipple,  401. 
of  tongue,  401,  403. 
of   tonsil,   401. 
relapsing,  401. 
source  of  infection,  449. 
time  of  appearance  of,  393,  399. 
treatment  of,  404. 
ulceration  of,   399. 
varieties  of,  400. 


650 


II^DEX. 


Chancroid,  403. 

Chantemesse  and  Podvryssotsky,  on  hered- 
ity in  neoplasms.  515. 
Chapman,  on  frequency  of  dysmenorrhea, 

66. 
Charpentier,    on    measles    as    a    cause    of 

abortion,  455. 
Chart  showing   age   at  which  gonorrheal 
infection    is    most    frequent    in 
children,  383. 
Chasan,  S.,  case  of  smallpox  in  fetus  with 

healthy  mother,  454. 
Chase,  T.  H.,  on  appendicitis  and  chronic 
salpingitis      existing      independ- 
ently, 589. 
Chase,   W.   B.,   case   of  primary   amenor- 
rhea. 141. 
on  method  of  cauterizing  uterus  in  can- 
cer, 536. 
Cherry  laurel  water  in  pruritus,  301. 
Child,  appendicitis  in,  595. 
coccygodynia  in,  261. 
examination  of  pelvic  organs  in,  25. 
gonorrheal  vaginitis  in,  381,  389. 
Childbirth.     See  Labor. 
Childhood,  infectious  diseases  in,  a  cause 

of  pelvic  disease,  265. 
Children,  gonorrheal  peritonitis  in,  280. 
causes  of  ill-health  among,  41. 
movable  kidney  in,  609. 
remedies  for  constipation  in,  221. 
splanchnoptosis  in,  602. 
Chloasma,  uterine,  diagnosis  between,  and 

pigmentary  syphilide,  413. 
Chloral  hydrate,  as  vaginal  douche  in  in- 
operable cancer,  541. 
in  insomnia,  242. 
in  pruritus,  299. 
Chloroform  liniment  in  backache,  258. 

in  headache,  231. 
Chlorosis,   ages   at  which  most  frequent, 
147,  153. 
blood  in,  146,  153. 

blood  pigment  in  urine  during,  158. 
constipation  in,  119,  157. 
definition  of,  146. 
dysmenorrhea  in,  109. 
emotional  disturbances  in,  147. 
gastric  symptoms  in.  158. 
heart  and  arteries  in,  119. 


Chlorosis,  importance  of,  to  gynecologist, 
120. 
in  school-girls,  119. 
intestinal    antisepsis    in    treatment    of, 

157. 
menstrual    disturbances    in,    146,    147, 

153,  179,  180,  367. 
nervous  symptoms  in,  147,  158. 
obesity  associated  with,  244,  245. 
pubert;s-  early  in,  147. 
relapses  in,  147. 
rest  in  treatment  of,  158. 
sexual  organs  in,  147. 
special  diathesis  in,  147. 
sterilit;^'  and,  367. 
treatment  of,  155. 
Cholera,  atresia  of  genital  tract  following, 

267. 
Chorio-epithelioma  cause  of  uterine  hem- 
orrhage, 171. 
de    Christmas,    on   toxic    product    of    the 

gonococcus,  379. 
Ciniselli,   on   electricity   in   treatment   of 

fibroid  tumors,  507. 
Circulation,     disturbances     of,     abortion 
from,   455. 
constipation  from,  207,  208. 
in  movable  kidney.  613. 
in  neurasthenia,  567. 
uterine  hemorrhage  from,  180. 
Circulatory  system,  syijhilis  of,  424. 
Claisse,  A.,  on  etiology  of  fibroid  tumors, 

494. 
Clark,  Sir  A.,  on  copremia  as  a  cause  of 

chlorosis,  143,  147,  161. 
Clark,  J.  G.,  on  radical  operation  for  can- 
cer, 530. 
Clark   and  Pancoast,   on   redundant   sig- 
moid  in   causation    of    constipa- 
tion, 213. 
on  splanchnoptosis,  597. 
Climate,  influence  of,   on  first  menstrua- 
tion, 83. 
on  suppression  of  menstrual  flow.  149. 
Clothing,  unsuitability  of,  in  women,  70. 
Coal-tar  preparations,  dangers  of,  235. 
in  dysmenorrhea,  114. 
in  headache,  158,  235. 
in  inoperable   cancer.    541. 
necessity  of  stimulants  with,  114,  235. 


INDEX. 


651 


Cobbe,  Y.  P.,  on  domestic  infelicity  as  a 
cause  of  headache  in  women,  227. 
Cocain,  in  nasal  dysmenorrhea,  109. 

in  pruritus,  300. 

in  coccygodynia,  264. 

in  vaginismus,  271. 

in  vomiting,  158. 

injection  of,  under  spinal  cord,  258. 
Cocain  anesthesia.     See  Anesthesia. 
Cocain  ointment.     See  Ointment. 
Coccygodynia,   260. 

diagnosis  of,  263. 

etiology   of,  261. 

examination  in,  263. 

faradization  in,  263. 

first  operation  for,  261. 

frequency  of,  263. 

massage  in,  263. 

neuralgia  and,  262. 

pain  in,  character  of,  262. 

pelvic  disease  and,  262. 

pregnancy  and,  261,  262. 

relation  of,  to  rheumatism,  261. 

treatment  of,  263. 
Coccyx,  bimanual  examination  of,  29. 
Coe,  H.  C,  on  appendicitis  and  disease  of 
uterine  adnexa,  587. 

on  malaria  and  ovarian  pain,  272. 

on  relation  between  internal  secretion 
and     amenorrhea    with     obesity, 
148. 
Coifee,  cause  of  insomnia,  239,  241. 
Coffey's    operation    for    displacement    of 

stomach,  604. 
Cohn,  H.,  on  myopia  in  school  children, 

57. 
Cohnheim's  theory  of  neoplasms,  494,  515. 
Cold,  exposure  to,  a  cause  of  functional 

amenorrhea,  149,  159. 
College   life,    influence    of,    on   health    of 

young  women,  76. 
College  women,  dysmenorrhea  in,  77. 
Colitis,  mucous,  574,  601. 
Colles'  law,  448. 

Colon,  atony  of,  a  cause  of  constipation, 
213. 

examination  of,  36. 
Colon  bacillus  infection,  effect  of  urotro- 
pin  on,  557. 

in  cystitis,  550. 


Colonoscope,  37. 

Col  taperoides,  361. 

Complexion,  effects  of  constipation  upon, 

207. 
Compress,  cold,  in  headache,  231. 
Condylomata,  diagnosis  between,  and  non- 
syphilitic  vegetations,  416. 

formation  of,  400. 

in   infantile  syphilis,  443. 

in  moist  papular  syphilide,  415,  416. 

treatment  of,  442. 
Conglutination  of  labia,  a  cause  of  pri- 
mary amenorrhea,  144. 
Conjunctiva,  gonorrheal  infection  of,  378. 
Conservatism  in  treatment  of  pelvic  in- 
flammation, 344. 
Constipation,  207. 

backache  from,  208,  251. 

classification  of,  214. 

defective  toilet  accommodations  a  cause 
of,  212. 

definition  of,  207. 

diagnosis  of,  214. 

diet  for,  217. 

during  rest  cure,  580. 

dysmenorrhea  associated  with,  113,  208. 

effects  of,  207. 

enemata  for,  221. 

etiology  of,   212. 

exercise  in  prevention  of,  213,  218. 

frequency  of,  213. 

galvano-faradism  for,  218. 

headache  caused  by,  214,  227. 

in   amenorrhea,    155. 

in  chlorosis,  147,  157. 

in  enteroptosis,    601. 

in  growing  girl,  53,  68. 

in  neurasthenia,  567. 

insomnia  caused  by,  241. 

masturbation  caused  by,  310. 

mental  influence  in  treatment  of,  216. 

migraine  caused  by,  236. 

morbid  growths   a   cause   of,   213,   215, 
222. 

movable  kidney  caused  by,  608. 

post-operative,   625. 

prophylaxis  of,  216. 

retroflexion  of  uterus  a  cause  of,  33. 

torpidity  of  liver  in,  222. 

treatment  of,  157,  216. 


652 


IKDEX. 


Constitutional  diseases,  cause  of  abortion, 
455. 
cause  of  amenorrhea,  l-iS. 
cause  of  uterine  hemorrhage,  179. 
danger  of  curettage  in,  190. 
indication  for  artificial  abortion,  171. 
Consulting  room,  1. 
Contagion,  danger  of,  in  pruritus,  299. 

question  of,  in  cancer,  515. 
Copaiba,  in  treatment  of  cystitis.  559. 
rash  from,  mistaken  for  syphilitic  erup- 
tion, 112. 
Copremia,  117,  157,  207,  241. 
Cornea,  syphilis  of,  428. 
"  Corona  veneris,"  414. 
Corpus    luteum,     administration     of,     in 
amenorrhea,  159,  245. 
association  of,  with  obesity,  244. 
disease  of,  a  cause  of  hematoma,   335, 

340. 
influence  of,  upon  menstruation,  80,  139. 

upon  ovum,  79. 
relief   of  symptoms   at  menopause,   ad- 
ministration of,  for,  95,  630. 
Corset,  tight,  hindrance  of,  to  action  of 
bowels,  213. 
to  breathing,  218. 
injury  done  by,  to  growing  girl,  70. 
splanchnoptosis  caused  by,  599. 
Coryza,  syphilitic,  434. 
Cotton-root,  abortion  caused  by,  456. 
Cousins,  marriage  of,  in  relation  to  steril- 
ity, 368. 
Craig,  D.  H.,  on  early  symptoms  of  can- 
cer, 519. 
method  of  curetting  cervix,  289. 
Craig's   curette,  289,   374. 
Cucca  and  Ungaro,  on  methylene  blue  in 
treatment  of  uterine  cancer,  537. 
Cullen,  T.  S.,  on  danger  of  tents  in  dila- 
tation of  cervix,  122. 
on  fibroid  tumors,  99,  492. 
on  formalin  method  of  preparing  micro- 
scopical specimens,  193. 
Cupping  glass,  Thomas',  461. 
Cups,  dry,  in  treatment  of  dysmenorrhea. 

116. 
Curettage  of  cervix.     See  Endocervicitis. 
Curettage  of  endometrium,  before  \ise  of 
acetone,  540. 


Curettage   of   endometriiun,   for   endome- 
tritis, 294. 

for  fibroid  tumors,  188,  510. 

for  inoperable  cancer,  534. 

in  abortion,  190,  469,  470. 

in  diagnosis  of  cancer,  170,  526. 

in  sterility,  373. 

instruments  for,  123. 

method  of,  189. 

risks  in,  189,  373,  468. 

rules  for,  189. 
Curette,  Craig's,  290,  374. 

irrigating,   526. 

loop,  535. 

sharp,  189,  190,  469. 

spoon,  189,  535. 
Cushion,  obstetrical,  486. 
Cystitis,   543. 

albumen  in,  549. 

ascending,   544. 

catheterization  a  cause  of,  386,  544. 

constitutional  symptoms  of,  548. 

cystoscopic  examination  of  bladder  in, 
387,  550. 

definition    of,    543. 

descending,  544. 

diagnosis    of,    548. 

differential  diagnosis  of,  554. 

drugs  in  treatment  of,  559. 

etiology  of,   544. 

gonorrheal,  386,  558. 

infections  causing,  386,  543,  549,  550,  558. 

instillations  in  treatment  of,  560. 

irrigation   in,   561. 
continuous,  564. 

labor,  followed  by,  480,  486,  555. 

latent,  544. 

method  of  taking  history  in,  546. 

opsonic  treatment  of,  562. 

post-operative,  544,  555. 

preventive  treatment  of,  488,  554. 

situations  of,  543,  553. 

symptoms   of.    547. 

topical  treatment  of,  561. 

tubercular,   554,   557. 

iirinary  symptoms  of,  547. 

vaginal  drainage  in,  562. 

varieties  of.  543. 
Cystoeele,  Gehruug  pessary  for,  327. 

in  gynecological  examination,  19. 


INDEX. 


653 


Cystoscope,  Kelly  open-air,  550,  552,  561. 
Cysts,  blood,  366. 

Graafian,  366. 

of  Bartholin's  glands,  276. 

of  corpus  luteum,  177,  340. 

ovarian,  340,  366,  588,  590. 

papillary,  340. 

parovarian,  366,  373. 

Dactylitis,  syphilitic,  428. 

Dana,  C.  L.,  on  phrenasthenia,  569. 

Daniel,  C,  on  disease  of  adnexa  associated 

with  fibroid  tumor,  497. 
Darwin,  G.,  on  marriage  of  cousins,  in  re- 
lation to  sterility,  368. 
Davidson  syringe,  331. 
Decidua,    dangers    of   retention   of,    after 
abortion,  457. 

gonoccoecus  affecting,  378. 

inflammation  of,  456. 
Deciduoma  malignum.   See  Chorio-epithe- 

lioma. 
Defecation,  act  of,  208. 

factors  in,  209. 

involuntary,  209. 

pain  during,  in  coccygodynia,  262. 

proper  posture  in,  210,  211. 
Deferinitis,  cause  of  male  sterility,  352. 
Defloration,  signs  of,  359. 
Deletzine  and  Volkoff,  on  movable  kidney 

in  the  two  sexes,  608. 
Dercum's  disease,  248. 
Dermo-pulmonary  fumigation  method  of 

treating  syphilis,  439. 
Descensus  of  uterus.     See  Uterus. 
Desk,  school,  60. 
Diabetes,  amenorrhea  caused  by,  148. 

pruritus  caused  by,  295,  297,  302. 

syphilis  in  etiology  of,  397. 
Diarrhea  in  neurasthenia,   567. 
Dickinson,  R.  L.,  on  elasticity  of  hymen, 
313. 

on  uterine  hemorrhage  from  sclerosis  of 
blood-vessels,  177. 
Dickinson's  two-way  catheter,  559,  560. 
Diet,  in  chlorosis,  156. 

in  constipation,  217. 

in  hemorrhage  from  uterus,  509. 

in  movable  kidney,  615. 

in  obesity,  245,  247. 


Diet,  in  post-operative  convalescence,  625. 
in  pruritus,  299. 
in  rest  cure,  580,  581,  582. 
in  septic  abortion,  470. 
in  splanchnoptosis,  603. 
regular,  during  menstruation,  73. 
in  prevention  of  headache,  233. 
in  prevention  of  insomnia,  241. 
in  prevention  of  migraine,  237. 
Diet  lists  for  constipation,  217. 

for  obesity,  247. 
Dietetics,  knowledge  of,  68. 
Dietl,  on  attacks  of  pain  in  movable  kid- 
ney, 610. 
Dietl's  crises,  600,  601,  609,  613. 

artificial  production  of,  29,  610,  613. 
Digestion,     disturbances     of,     cause     of 
amenorrhea,  148. 
in  neurasthenia,  567. 
effects  of  constipation  on,  207. 
process  of,  208. 
Dilatation  of  cervix.     See  Cervix. 

of  sphincter  for  fissure  of  rectum,  38. 
of  vaginal  orifice,  308. 
Dilator,  conical,  for  sphincter,  35. 
Dilators,  Goodell-Ellinger,  124,  190,  373, 
469,   501. 
Hanks',  387. 
Hegar's,  122,  482. 
Diphtheria,  atresia  of  genital  tract  from, 

267. 
Diphtheritic  vaginitis,  281. 
Dirmoser,  E.,  case  of  inflammation  of  ute- 
rine appendages   during  typhoid 
fever,  269. 
Diseases,  acute,  followed  by  amenorrhea, 
148,  153,  159. 
chronic,    accompanied   by    amenorrhea, 

148,   153. 
exhausting,   followed  by   splanchnopto- 
sis, 599,  602. 
Displacements  of  uterus.     See  Utertis. 
Diuretics  in  treatment  of  headache  during 

pregnancy,  233. 
Dobell's  solution  in  treatment  of  syphilis, 

442. 
Dohm,  on  presence  of  gonococcus  in  mu- 
cous membrane,  378. 
Doleris,  on  colloid  degeneration  of  fibroid 
tumors,  496. 


654 


INDEX. 


Domestic  science,  compulsory  instruction 

in,  at  school,  42. 
Domestic   unhappiness   a   cause   of  head-  ; 

ache,  227. 
Dori,    on    hypodermic    administration    of 

iron  in  chlorosis,  156. 
Douches,  vaginal.     See  Vaginal  douches. 
Douleurs  interrtienstruelles,  132. 
Dover's  powder  in  treatment  of  acute  lum- 
bago, 250. 
Drappier,  on  alcoholic  poisoning  as  cause 

of  abortion,  456. 
Dress  of  school-girl,   53. 
Drugs,  abortion  induced  by,  456. 
Dubois,  Paul,  on  psychotherapy,  in  treat- 
ment of  constipation,  216. 
in  treatment  of  neurasthenia,  584. 
on  milk  in  treatment  of  nervous  disor- 
ders, 579. 
Ducrey's  bacillus,  400. 
Dudley,  E.  C,  on  packing  uterus  for  hem- 
orrhage from  fibroid  tumors,  509. 
Dmnitriu,   on  use  of  curette  for  incom- 
plete abortion,  468. 
Duncan,  J.,  on  chlorosis,  146. 
Duncan,  M.,  on  increase  of  sterility,  348. 

on  spasmodic  dysmenorrhea,  108. 
Dunning,  H.  L.,   on  senile  endometritis, 

294. 
Dupuytren,    on   frequency   of   fibroids   in 

married  women,   494. 
Dupuytren's  pills  in  treatment  of  syphilis, 

438. 
Dust,  dangers  of,  in  schools,  58. 
Dysentery,  atresia  of  genital  tract  caused 
by,  266. 
inflammation  of  uterus  in,  269. 
Dysmenorrhea,  105. 

associated  with  acute  appendicitis,  595. 
with  chronic  appendicitis,  592. 
with  fibroid  tumors.  111,  498. 
with  general  ill-health,  109. 
with  gout,  110. 
with  maldevelopment  of  reproductive 

organs,  108. 
with  neurasthenia,  109,  565,  592. 
with   pelvic    inflammation.    111,    337, 

338. 
with  rheumatism,  96,  110. 
with  sterility,  373. 


Dysmenorrhea,  calcium  lactate  in,  117. 
causes  of,   in  absence  of  gross  lesions, 
107. 

in  presence  of  gross  lesions,  110. 
dilatation  of  cervix  for,  107,  121,  373. 
electricity  for,  117. 
examination  of  pelvic  organs  in,  112. 
formulae  for  relief  of,  114,  115. 
from  constipation,  113,  208. 
from  overloaded  rectum,  33. 
general  remedial  measures  for,  112. 
in  college  women,  77. 
in   displacements    of   uterus,    110,    318, 

320. 
in  school-girls,  66. 
mechanical,  107. 
nasal,  109. 
neuralgic,  110. 
neurotic,  108. 

operative  treatment  for,  120,  126. 
ovarian,  110. 
pessaries  for,  117. 
reflex  symptoms  in,  106. 
remedies  for  immediate  relief  of,  113. 

for  permanent  relief  of,  117. 
thyroid  extract  in,  117. 
varieties  of,  106. 
Dysmenorrhea,  membranous,  128. 

associated  with  sterility,  131. 

character  of  pain  in,  129. 

clinical   history   of,   129. 

definition  of,  128. 

diagnosis  of,  130. 

etiology  of,  129. 

history  of,  128. 

macfoscopical  appearances  in,  129. 

mechanism    of    separation    of    mem- 
brane in,  130. 

microscopical  appearances  in,  129. 

treatment  of,  131. 
Dyspareunia,  367. 

Ear,  gonorrhea  of  mucous  membrane  in, 

378. 
syphilis  of,  429. 
Ears,  condition  of,  in  school-girls,  57. 
Ebell,    case    of    atresia    of    genital    tract 

caused  by  cholera,  267. 
Eberlin,   case   of  atresia  of  genital  tract 

caused  by  typhoid  fever,  266. 


INDEX. 


655 


Ebstein,  on  treatment  of  obesity,  248. 
Eclampsia,   indication  for  artificial  abor- 
tion, 474. 
Ecthyma  vulgaris,  diagnosis  between,  and 

ecthyma  form  of  syphilide,  418. 
Eczema,  impetiginous,  diagnosis  between, 
and  impetiginous  form  of  syphil- 
ide,  417. 
Eczema  of  palms,  diagnosis  between,  and 

syphilis,  415. 
Eczema  of  vulva,  cause  of  masturbation, 
310. 
cause  of  pruritus,'  296. 
diagnosis  between,  and  vulvitis,  276. 
Edema,  localized,  during  artificial  meno- 
pause, 628. 
Edematous  degeneration  of  fibroid  tumor, 

496. 
Edgar,  J.  C,  method  of  dilating  cervix  in 

labor,  482,  483. 
Edgecombe,  on  fall  in  percentage  of  hemo- 
globin during  day,  158. 
Education  of  mothers,  40,  41,  52. 
Education  of  public,  prophylaxis  of  can- 
cer by,  520,  530. 
of  infectious  diseases,  50. 
of  syphilis,  449. 
Egypt,  age  of  first  menstruation  in,  83. 
Eieholz,  on  physical  deterioration,  41. 
Einhorn,  on  frequency  of  splanchnoptosis, 

602. 
Electricity  in   treatment   of   amenorrhea, 
155. 
of  coecygodynia,  260. 
of  constipation,  218,  223. 
of  dysmenorrhea,  117. 
of  fibroid  tumors,  507. 
of  functional  neuroses,  577. 
of  headache,  531. 
of  insomnia,  241. 
of  intermenstrual  pain,  136. 
of  pruritus,  502. 
of  sacro-iliac  rheumatism,  258. 
of  splanchnoptosis,  603. 
of  uterine  hemorrhage,  187. 
of  vaginismus,  307. 
Embolism,  in  anemia  from  fibroid  tumors, 
504. 
post-operative,  630,  631. 
Emmenagogues,  160. 


Emmet,  T.  A.,  on  age  of  first  menstrua- 
tion, 82. 

on  cervical  cancer  in  nullipara?,  517. 

on  congestive  dysmenorrhea,  116. 

on  injury  to  cervix  a  cause  of  abortion, 
456. 

on  irregularity  of  menstruation  at  pu- 
berty, 86. 

on  length  of  menstrual  period,  84. 
Emphysematous  vaginitis,   281. 
Emplastrum  de  Vigo,  442. 
Endocarditis,  association  of,  with  fibroid 
tumor,  505. 

gonorrheal,  377,  378. 

syphilitic,  425. 
Endocervicitis,  287. 

cause  of  sterility,  361. 

symptoms  of,  287. 

treatment  of,  287. 
Endometritis,  abortion  caused  by,  456. 

acute,  174,  291. 

chronic,  174,  291. 

caused  by  constipation,  208. 

danger  of  uterine  treatment  in,  31. 

definition  of,  291. 

discharge  in,  20. 

dysmenorrhea  caused  by,  110. 

following  labor,  480. 

glandular,  175,  292. 

gonorrheal,  291. 

intermenstrual  pain  caused  by,  136. 

malarial    influences    in,    271. 

membranous  dysmenorrhea  from,  129. 

polypoid,  175,   180,  292. 

precocious  menstruation  from,  82. 

pruritus  from,  296. 

rarity  of,  175,  291,  292. 

sterility  caused  by,  362. 

tubercular,  176,  291. 

varieties  of,  293. 

uterine  hemorrhage  from,  174,  293. 
Endometrium,   changes   in,   at  menstrua- 
tion, 80,  81. 
from  cancer,  527,  529. 

curettage  of.     See  Curettage. 

examination  of  scrapings  from,  191,  527. 

gonorrheal  infection  of,  in  children,  269. 

hypertrophy  of,  a  cause  of  hemorrhage, 
175. 

irritation  of,  by  stem  pessary,  155. 


656 


INDEX. 


Endometrium,  normal,  80,  193,  528. 

rarity  of  inflammatory  changes  in,  291. 
tuberculosis  of,  176,  291. 
Endoscope,  Kelly,  in  treatment  of  gonor- 
rhea, 387. 
Engelmann,  G.,  on  age  of  first  menstrua- 
tion in  America,  83. 
on  frequency  of  menstrual  pain,  66. 
on  menstruation  in  college  women,  77. 
Enemata,  rectal,  arsenic  administered  by, 
272. 
caution  in  use  of,  222. 
cotton-seed  oil,   222. 
flaxseed,  32,  222,  625. 
formulae  for,  222. 
in  constipation,  221. 
in  post-operative  convalescence,  222. 
in  rest  cure,  580. 
in   splanchnoptosis,   603. 
purgative,   222. 
sedative,  115,  299. 
Enteritis,  ulcerative,  associated  with  syph- 
ilis, 423. 
Enteroptosis.     See  Splanchnoptosis. 
Epididymis,  syphilis  of,  425. 
Epididymitis,  cause  of  male  sterility,  352. 
Epilepsy,  due  to  syphilo-toxines,  397. 

relation  of,  to  migraine,  228. 
Epithelioma,  diagnosis  between,  and  syph- 
ilis of  oro-pharyngeal  cavity,  423. 
Epithelium,  columnar,  gonococcus  infec- 
tion of,  378. 
squamous,  gonococcus  infection  of,  378. 
Epispadias,   cause  of  male   sterility,   347, 

352. 
Epsom  salts.     See  Magnesium  sulphate. 
Erb,  on  galvano-faradism  in  treatment  of 

constipation,  218. 
Ergot  in  expectant  treatment  of  abortion, 
463. 
in  hemorrhage  after  abortion,  469. 
in  uterine  hemorrhage,  185,  508. 
Ergotin  in  headache  with  low  arterial  ten- 
sion, 233. 
in  uterine  hemorrhage,  185. 
Erosions  of  cervix.     See  Cervix. 
Eruption,  syphilitic,  394,  411. 
Eruptive  fevers.     See  Exanthemata. 
Erysipelas,  abortion  caused  by,  455. 

atresia  of  genital  tract  caused  by,  267. 


Erythema  multiforme,  diagnosis  between, 

and  a  syi^hilitic  eruption,  412. 
Erythema  of  mouth  and  throat,  syphilitic, 

421. 
Esophagus,  syiDhilis  of,  423. 
Esquimaux,     age    of    first    menstruation 

among,  83. 
Ethyl,  chloride  of,  local  anesthesia  from, 

277. 
Examination,  gynecological,  5. 
abdominal,   6. 
anesthesia  in,  26. 
bimanual,  11. 
by  inspection,  19. 
by  palpation,  10. 
by  rectum,  33. 
gauze  records  in,  17. 
in  child,  25. 

in  knee-breast  posture,  23. 
in  Sims'  posture,  23. 
in  virgins,  27. 
notes  of,  29. 
of  colon,  9. 
of  gaU-bladder,  8. 
of  hemorrhoidal  region,  38. 
of  kidney,  7. 
of  liver,  8. 

of  sigmoid  flexure,   9. 
of  stomach,  9. 
of  vermiform  appendix,  9. 
of  vulva,  19. 
pain  in,  27. 
standing,  26. 
trimanual,  13. 
vaginal,  10. 
Examining   room,   1. 
Examining  table,  6. 
Exanthemata,  endometritis  due  to,  270. 
membranous  dysmenorrhea  from,  129. 
ovaries  affected  in,  268,  270. 
Excitement,  amenorrhea  due  to,  149. 
insomnia  due  to,  238. 
migraine  due  to,  237. 
Exercise,    outdoor,    during   menstruation, 
73. 
effect  of,  on  hemoglobin,  158. 
for  school-girl,  61. 
importance  of,  at  puberty,  68. 
in  amenorrhea,  155. 
in  constipation,   218. 


INDEX. 


657 


Exercise,  outdoor,  in  dysmenorrhea,   113. 

in  headache,  231. 

in  pelvic  diseases,   30. 

in  prophylaxis  of  migraine,  237. 

in  pruritus,  299. 

lack    of,     a    cause    of    constipation, 
199. 
Exercises,  breathing,  in  constipation,  218. 
gymnastic,  for  school-girl,  59. 

in  constipation,  218,  223, 

in  headache,  232. 

in  movable  kidney,  618. 

in  splanchnoptosis,  603. 
Exfoliative  vaginitis,  281. 
Exophthalmos,  576. 

Exstrophy  a  cause  of  male  sterility,  352. 
Extension  in  treatment  of  sacro-iliac  joint 

relaxation,  259. 
Extra-uterine  pregnancy.    See  Pregnancy. 
Eye,  syphilis  of,  428. 
Eyelid,  chancre  of,  401. 
Eyes,  examination  of,  in  school-girls,  56. 
Eyestrain,  at  menstrual  periods,  106. 
headache  caused  by,  226. 
in  school-girls,  56. 

Faradic  current.    See  Electricity. 
Fatigability,  characteristic  of  neurasthe- 
nia, 567,  573. 
Fatigue,  avoidance  of,  in  prophylaxis  of 

migraine,  237. 
Fatty    degeneration    of    heart    associated 

with  fibroid  tumors,  504. 
Fatty  infiltration  of  heart  associated  with 

fibroid  tumors,  504. 
Fenwick,    on   association  between   fibroid 

tumor  and  heart  disease,  505. 
Fermentation  in  lower  intestine  a  cause  of 

headache,  227. 
Fetus,  adhesions  between,  and  membranes, 
454. 
death  of,  from  infection,  454. 
deformities   of,   from   hemorrhage   into 

chorion,  454. 
unusual  size  of,  a  cause  of  extra-uterine 
pregnancy,  195. 
Fever,     during    post-operative     convales- 
cence, 634. 
headache  due  to,  226. 
syphilitic,  394. 


Fibro-cystic    degeneration    of    fibroid   tu- 
mors, 496. 
Fibroid  tumors,  abortion  due  to,  499,  504. 

age  at  which  most  frequent,  493. 

anemia  from,  498,  504. 

ascites  mistaken  for,  500. 

cancer  of  pelvis  mistaken  for,  500. 

classification  of,  489. 

complications  of,  496. 

constipation  from,  503. 

danger  to  life  from,  505. 

definition  of,  488. 

degeneration  of,  495. 

delivery  obstructed  by,  480,  503,  504. 

diagnosis  of,  498. 

direction  of  grovTth  of,  490. 

dysmenorrhea  from.  111,  498. 

effect  of,  on  distant  organs,  504. 
on  neighboring  organs,  503. 

etiology  of,  494. 

in  families,  494. 

frequency  of,  493. 

gauze  record  of,  19. 

gelatin  in  treatment  of,  508,  509. 

heart  disease  associated  with,  504. 

hemorrhage  from,  168,  180,  497,  506. 

heredity  in  causation  of,  494. 

infection  in  causation  of,  494. 

infection  of,  496. 

in  negro  race,  493. 

in  old  age,  640. 

interstitial,  diagnosis  of,  500. 

distortion  of  uterine  cavity  by,  490. 
locations  of,  490. 

intra-uterine  treatment  of,  509. 

latent,  495. 

leucorrhea  in,  498. 

life  history  in,  494. 

origin  of,  489. 

packing  in  treatment  of,  509. 

pain  in,  498. 

pedunculate,  168,  169,  499,  501,  510. 

pelvic  inflammation  complicating,  500. 

pregnancy  with,  499,  512. 

radical  operation  for,  512. 

rectum  choked  by,  33. 

rest  in  treatment  of,  506. 

sexual  irritation  a  cause  of,  494. 

situations  of,  493. 

sterility  from,  363,  364,  373,  499,  504. 


658 


INDEX. 


Fibroid  tumors,  structure  of,  488. 
submucous,  168,  .500. 
diagnosis  of,  501. 

distortion  of  uterine  cavity  by,  491. 
dysmenorrhea  from,  111. 
expulsion  of,  from  cervix,  491. 
manner  of  growth  of,  491. 
method  of  removal  of,  510. 
non-operative  treatment  of,  506. 
surgical  treatment  of,  509. 
subperitoneal,  diagnosis  of,  499. 
dysmenorrhea  from,  111. 
manner  of  growth  of,  490. 
non-operative  treatment  of,  506. 
stypticin  in  treatment  of,  508. 
symptoms  of,  497. 
thyroid  extract  in  treatment  of,  508. 
treatment  of,  505. 
ureters  compressed  by,  503. 
vaginal  douches  in  treatment  of,  508. 
varieties  of,  489. 
Fibromyoma.     See  Fibroid  tumor. 
Fibrosis  of  external  genitalia  a  cause  of 

pruritus,  296. 
Finger,  on  azoospermia,  296. 

on  inoculation  of  monkeys  with  syphi- 
litic serum,  398. 
Fischel,  on  vicarious  menstruation,  162. 
Fish-berries,  decoction  of,  in  treatment  of 

pruritus,  298. 
Fistula,  cervico-vaginal,  478. 

repair  of,  486. 
Fissures  in   ano,  cause   of   masturbation, 
310. 
treatment  of,  in  j)rophylaxis  of  abortion, 
461. 
Fissures  of  rectum  mistaken  for  disease  of 

uterus  and  ovaries,  34. 
Flaischler,  on  treatment  of  pruritus,  301. 
Flat-foot,  neurasthenia  from,  568. 
Flaxseed  enemata.     See  Enemata. 
Fleck,  on  relation  between  fibroid  tumors 

and  heart  disease,  505. 
Fleiss,  on  nasal  dysmenorrhea,  109. 
Fletcher  system  of  mastication,  580. 
Forceps,  alligator,  35,  38. 
axis  traction,  482,  483. 
rules  for  use  of  obstetric,  482. 
Forchheimer,   on  treatment  of   chlorosis, 
157 


Formalin   in   preservation    of    specimens, 
193. 
in  treatment  of  cervical  cancer,  536. 
in  treatment  of  gonorrhea,  388. 
Formulae  for  use  in  abortion,  461,  472. 
in  amenorrhea,  156,  157,  158. 
in  backache,  256. 
in  constipation,  220. 

in  a  child,  221. 
in  cystitis,  558,  559,  561. 
in  disinfection,  324,  331. 
in  dysmenorrhea,  114,  115. 
in  gonorrhea,  386.. 
in  headache,  231,  232,  234,  235. 
in  insomnia,  243. 

in  post-operative  convalescence,  624. 
in  pruritus,  298,  300,  301,  302,  303. 
in  vaginitis,  284. 
in  vulvitis,  277. 
Fournier,  on  chronic  intermittent  method 
of  treating  syphilis,  441. 
on  conditions  necessary  for  curing  syph- 
ilis, 441. 
on   digital    chancre    among   physicians, 

402. 
on  late  syphilitic  lesions,  445. 
on   mercury   in   treatment    of   syphilis, 

437. 
on  mildness  of  secondary  symptoms,  395, 

396. 
on  smoking  as  a  cause  of  cancer  in  syph- 
ilitic subjects,  441. 
on     statistics     of     hereditary     syi^hilis, 

432. 
on  transmission  of  syphilis  to  third  gen- 
eration, 436. 
Fowler,    on   mistaken    diagnosis    between 
appendicitis    and    dermoid    cyst 
with  torsion  of  pedicle,  590. 
Friinkel,  L.,  on  chlorosis,  147. 

on  corpus  luteum  and  menstruation,  79, 
139,  150. 
von  Franque   on  membranous   dysmenor- 
rhea. 128. 
Freeman,  R.  D.,  on  appendicitis  in  child, 

simulating  hip  disease,  596. 
Freud,  on  psycho-analysis,  583. 
Freund,  on  fatty  degeneration  of  fibroid 
tumor,  496. 
on  hyperthyroidism,  575. 


INDEX. 


659 


Friedenwald  and  Eulirah,  on  diet  in  obes- 
ity, 246. 

Friedrichshall  water,  use  of,  in  constipa- 
tion, 221. 

Fright,  a  cause  of  amenorrhea,  149. 

Fritsch,  on  gonorrheal  infection  of  rectal 
mucous  membrane,  378. 
on  necessity  for  cultures  in  gonorrhea, 
385. 

Frontal  sinus,  headache  from  disease  of, 
226. 

Functional  amenorrhea,  149. 

Furuncle,  diagnosis  between,  and  chancre, 
403. 

Gallant's  corset  for  splanchnoptosis,  603. 
Gall-bladder,  examination  of,  8. 

distention  of,  mistaken  for  movable  kid- 
ney, 614. 
Gall-stones,  simulation  of,  by  movable  kid- 
ney, 613. 
Galvanic  current.     See  Electricity. 
Ganglion  of  fifth  nerve,  removal  of,  for 

headache,  234. 
Gangrene  in  fibroid  tumors,  494. 
Garbage,  adequate  removal  of,  a  hygienic 

necessity,  44. 
Gastrectasy,  600. 

Genital  tract,  atresia  of,  primary  amenor- 
rhea from,  142. 
infectious  diseases  a  cause  of,  266. 
Garrigues,  on  age  of  first  menstruation, 
82. 
on  duration  of  menstrual  period,  84. 
Gastric  symptoms  in  chlorosis,  158. 

in  dysmenorrhea  associated  with  retro- 
flexion, 111. 
in  migraine,  229. 
in  movable  kidney,  611. 
in  neurasthenia,  567. 
in  splanchnoptosis,  600. 
Gastritis,  acute,  simulation  of,  by  movable 

kidney,  611. 
Gastro-intestinal      tract,      auto-infection 
from,  227. 
syphilis  of,  421. 
Gastropexy,  Beyea's  method  of,  604. 
Gastroptosis,  597. 

Gauze,  bichloride,  preparation  of,  466, 
Gauze  records,  17. 


Gebhard,  case  of  primary  amenorrhea  due 
to  atresia  of  hymen,  151. 
on   changes   in  glands   associated   with 

obesity,  367. 
on  etiology  of  fibroid  tumors,  494. 
Gellhorn,  G.,  on  acetone  in  treatment  of 
inoperable  cancer,  539. 
on  exfoliative  vaginitis,  581. 
Genitalia,  external,  changes  in,  from  mas- 
turbation, 312. 
changes  in,  from  pruritus,  297. 
Genital  organs,  female,  aplasia  of,  a  cause 
of  amenorrhea,  140,  146,  150. 
atrophy    of,     in    Basedow's     disease, 

148. 
local  changes  in,  at  menopause,  90. 
syphilis  of,  426. 
Genito-urinary  system,  disturbances  of,  in 
neurasthenia,  567. 
syphilis  of,  425. 
Gerota's  capsule,  606. 
Gibney,   V.   P.,   on  appendicitis   in  child 

simulating  hip  disease,  596. 
Giemsa's   method   of   staining  the   spiro- 

cheta  pallida,  392. 
Gilles,  on  syphilis  of  spinal  cord,  431. 
Gilliam,    on    age    of    first    menstruation, 
82. 
on  duration  of  menstrual  period,  84. 
Gin  in  treatment  of  dysmenorrhea,  114. 
Glans  penis,  chancre  of,  401. 
Glenard,    on   enteroptosis,    597,    599,    600, 
602. 
on  movable  kidney,   607. 
Glenard's  belt  test,  601. 
disease,  597. 
elastic  bandage,  603. 
Glossitis,  diagnosis  between,  and  syphilis 

of  oro-pharyngeal  cavity,  622. 
Gloves,   rubber,  necessity  for,  in  vaginal 
examinations  in  general,  11. 
in  gonorrheal  vaginitis,  282. 
in  labor,  486. 
Glycosuria  in  pruritus,  296,  297. 
Goehlert,    on   sterility   in   royal  families, 

368. 
Goelet,  on  electricity  in  treatment  of  dys- 
menorrhea, 118. 
Goldthwait,    on   relaxation   of   sacro-iliac 
joints,  252,  259,  260,  574. 


660 


rNDEX. 


Gonococcus,  bacterial  nature  of,  377. 

colorization  of,  378,  385. 

cultivation  of,  379. 

description  of,  377. 

detection  of,  385. 

isolation  of,  378. 

scarcity  of,  376. 

tissues  most  favorable  to,  378. 
Gonococcus  infection,   antigonococeus  se- 
rum for,   379. 

clinical  course  of,  380. 

cocain  anesthesia  in  treatment  of,  387, 
388. 

constitutional  treatment  of,  386,  391. 

curability  of,  380. 

danger  of  spreading,  during  treatment, 
6,  282,  286. 

definition  of,  375. 

diagnosis  of,  384. 

discharge  in,  298,  380,  381. 

douches  for.  389. 

dry  treatment  in,  389. 

effect   of,   on  distant  organs,   377. 

endometritis  caused  by,  291. 

examination  in,   385. 

history  of,  375. 

immunity  in,  379,  380. 

in  little  girls,  381,  389. 

in  pelvic  inflammation,  339. 

intentional  transference  of,  383. 

latent,  375,  384. 

localities  especially  subject  to,  275,  276, 
287,  357,  376. 

local  treatment   in,   386. 

male  organs  affected  by,  352. 

marriage  and,  384. 

organs  most  frequently  affected  by,  376. 

prevalence  of,  376. 

pruritus  caused  by,  296,  298. 

re-infection,  384. 

sequelae  of,  384. 

smears  from  secretion  of,  385. 

sterility  from,  in  female,  358,  365,  384. 
in  male,  354,  369,  384. 

tissues  affected  by  preference  by,  378. 

treatment  of,  386,  389. 

uterine  tubes  affected  by,  365,  381,  383. 

vaginismus  associated  with,  306,  307. 

vaginitis  caused  by,  280. 

vulvitis  caused  by,  275,  276. 


Gonococcus       infection,       vidvo-vaginitis 
caused  by,  in  little  girls,  381,  389. 
Gonorrhea.     See  Gonococcus  infection. 
Gonotoxine,   376,   379. 
Goodell,    W.,    on   treatment    of   pruritus, 

301,  302. 
"  Gospel  of  Comfort,"  347. 
Gossypiimi,  in  hemorrhage  after  abortion, 
469. 
in  threatened  abortion,  463. 
Goth,  L.,  on  aspirin  in  inoperable  cancer, 

541. 
Gottschalk,  on  etiology  of  fibroid  tumors, 
494. 
on  treatment  of  pruritus,  301. 
on    treatment    of    uterine    hemorrhage, 
185. 
Gout,    constitutional,    headache    due    to, 
225. 
migraine  due  to,  218,  229,  235,  236. 
obesity  due  to,  244.  245,  248. 
pruritus  due  to,  296. 
Gown,  obstetric,  486. 

Graefe,    ^il.,    on   relation   between    coecy- 
godynia  and  neuralgia,  262. 
on  treatment  of  coccygodynia,  263. 
von  Graefe's  sign,  575. 
Graves'    disease,    amenorrhea     associated 

with,  575. 
Gray  oil,  439. 
"  Green  mixture,"  115. 
Green  soap  in  pruritus   due  to  pediculi, 

298. 
Gummata  of  bones,  427,  428. 
of  brain,  431. 
of  esophagus,  423. 
of  iris,  429. 
of  joints,  428. 
of  kidney,  426. 
of  liver,  424. 
of  'lungs,   424. 
of  mammary  gland,  427. 
of  muscle,  427. 
of  periosteum,  427. 
of  peritoneum,  427. 
of  rectum,  423. 
of  testicles,  426. 
of  tongue,  422. 
of  trachea,  424. 
of  urethra,  425. 


INDEX. 


661 


Gummata  of  uterine  tubes,  427. 
of  uterus,  427. 
of  vertebras,  428. 
production  of,  398. 
treatment  of,  437. 
Gummatous   hepatitis,   423. 
Gusserow,  on  age  when  fibroid  tumors  are 
most  frequent,  493. 
on  fatty  degeneration  of  fibroids,  496. 
Gymnastic  exercises.     See  Exercises. 
Gymnasium  suit,  59,  60. 
Gynecological  examination.     See  Exami- 
nation. 
Gynecological      history-taking,      methods 
of,  3. 
scheme  for,  4. 
Gynecological  operations.     See  Operation 
and  Operative  treatment. 

Hair,  syphilis  of,  420. 
Hands,  sterilization  of,  6. 

vaginitis  due  to,  282. 
Harkin,  A.,  case  of  enlargement  of  paro- 
tid gland  during  successive  preg- 
nancies, 273. 
Harris,    on   characteristic   body   form   in 
splanchnoptosis,  602. 
on  etiology  of  movable  kidney,  608. 
Harris,  P.  A.,  on  method  of  dilating  cer- 
vix during  labor,  482,  483. 
Hart,  B.,  on  sacro-pubic  hernia,  11. 
Hart  and  Barbour,  on  age  of  first  men- 
struation, 82. 
on  age  when  fibroid  tumors   are  most 

frequent,  493. 
on  interval  between  menstrual  periods, 

86. 
on  length  of  menstrual  periods,  84. 
prescription  by,  for  constipation,  157. 
Haultain,      on     functional     amenorrhea, 

149. 
Hayem,  on  blood  pigment  in  urine  during 
chlorosis,  158. 
on    disturbances    of    menstruation    in 

chlorosis,  147. 
on  number  of  red  blood  corpuscles  in 

chlorosis,  153. 
on    oxylate    of    iron    in    treatment    of 

chlorosis,  156. 
on  rest  in  treatment  of  chlorosis,  158. 


Headache,  224. 

classification  of,  225. 

constipation  the  cause  of,  214,  227. 

diagnosis   of,   229. 

etiology  of,  224. 

formula}  for  relief  of,  231,  232,  234,  235. 

frequency  of,  224. 

hydrotherapy  for,   232. 

in  brain  disease,  226. 

in  chlorosis,  128. 

in  men,  225. 

in  neurasthenia,  225,  226,  228,  565. 

in  pregnancy,  233. 

in  syphilis,  226,  394,  440. 

investigation  into  cause  of,  226. 

menstrual,  105,  106,  226. 

nervous,  225. 

nocturnal,   226. 

outline  for  cases  of,  230. 

prophylaxis  of,  232. 

reflex,  225,  226. 

remedies  for  immediate  relief  of,  229. 

rheumatic,  225,  234. 

sedative  remedies  for,  234. 

sick.     See  Migraine. 

treatment  of,  229. 

varieties  of,  225. 

with  movable  kidney,  613. 
Health,  amenorrhea  from  disturbance  of, 
155. 

dysmenorrhea  from  disturbance  of,  109, 
112. 

general  care  of,  at  menopause,  93. 
at  menstrual  periods,  72. 

influences  injuring,  75. 

injurious     influence     of     malnutrition 
upon,  45. 
Health    of    community,    dependence     of, 

upon  public  sanitation,  44. 
Heart,  changes  in,  associated  with  fibroid 
tumors,  504. 
associated  with  obesity,  224. 
Heart  disease,  in  chlorosis,  147. 

indication  for  artificial  abortion,  474. 

sterility  caused  by,  367. 

uterine  hemorrhage  caused  by,  192. 
Heart,  syphilis  of,  424. 
Hebra,  on  pruritus,  295. 
Hegar,    on   disease    of   fetal    membranes, 
454. 


662 


INDEX. 


Hegar,    on   relation   between    absence   of 
sexual  feeling  and  sterility,  367. 
on    trauma    in    causation    of    abortion, 
455. 
Hegar's  graduated  dilators,  122,  482. 
sign  in  diagnosis   of  early  pregnancy, 
151,  500. 
Hellender,  on  septic  infection  in  abortion, 

463. 
Helonias  compounds,  in  treatment  of  dys- 
menorrhea,  115. 
Hematocele,    pelvic,    a    cause    of    uterine 

hemorrhage,  177. 
Hemogallol,    in    treatment    of    chlorosis, 

157. 
Hemoglobin,  increase  of,  in  obesity,  244. 
percentage  of,  an  indication  for  radical 

operations,  504,  511. 
reduction  of,  from  exercise,  158. 

in  chlorosis,  146,  153. 
reduction  of,  in  anemia  from  fibroid  tu- 
mors,  504. 
variations  in  percentage  of,  by  day  and 
by  night,  158. 
Hemorrhage,     uterine,     after     curettage, 
628. 
anemia  from,  182,  200,  498,  504. 
at  menopause,  88. 
constitutional  causes  of,  179,  192. 
constitutional  measures  of  relief  for, 

192. 
curettage  for,  189,  510. 
danger  to  life  from,  505. 
definition  of,  163. 
diagnosis  of,  180. 
during  infectious  diseases,  271. 
examination     of     pelvic     organs     in, 

181. 
examination  of  uterine  scrapings  in, 

191. 
family  tendency  to,  180. 
from  abortion,  165,  460,  464. 
from   calcification   of   uterine   blood- 
vessels, 178. 
from  corpus  luteum  cysts,  177. 
from  endometritis,  acute,  174. 
chronic,  174,  393. 
polyiioid,  175. 
tubercular,  176. 
from  enlarged  cystic  ovaries,  176. 


Hemorrhage,  uterine,  from  extra-uterine 
pregnancy,  175,  200. 
from  fibroid  tumors,  168,  180,  497. 
from    hypertrophy    of    endometrium, 

175,  293. 
from  imperfect  development  of  ute- 
rine blood-vessels,  180. 
from    inflammation    of    uterine    ad- 

nexa,  177,  337. 
from  inversion  of  uterus,  173. 
from  mucous  polyp,  166. 
from  placental  polyp,  166. 
from  retrodisplacements,  172,  322. 
general  means  of  relief  in,  192. 
in  cancer,  169,  170,  518,  519,  542. 
in  chlorosis,  147,  180,  367. 
in  chorio-epithelioma,  171. 
in  young  girls,  179. 
indication  for  artificial  abortion,  464. 
indication    for    radical    operation    in 

fibroid  tumor,  504,  510. 
investigation  into  causes  of,  180. 
local  causes  of,  165. 
mechanical  means   of  relief   of,   186, 

508,  509. 
medicinal  means  of  relief  of,  184. 
proportion    of    different   local   causes 

in,  178. 
rest  in  treatment  of,  183,  184,  506. 
saline  infusion  in  treatment  of,  184, 

206. 
vascular  causes  of,  179. 
vicarious,   160. 
Henderson,    on    conditions    of    work    in 

schools  and  colleges,  66. 
Henrotin,   F.,   on  drainage  in  pelvic  ab- 
scess, 342. 
Hepatic     disease,      uterine     hemorrhage 

from,   192. 
Hepatoptosis,  597. 

Heredity,   influence  of,  upon  age  of  pu- 
berty, 83,  145. 
Heredity    in    causation    of    cancer,    515, 
516. 
of  fibroid  tumors,  494. 
of  headache,  225,  226. 
of  insomnia,  238. 
of  obesity,  244. 
of  psyehasthenia,   572. 
of  vicarious  menstruation,  160. 


INDEX. 


663 


Heredity  in  prognosis  of  functional  neu- 
roses,  576. 
Herman,   on  treatment  of  chlorosis,  155, 
156. 
on  galvano-stem   pessary   in   treatment 
of  amenorrhea,  155. 
Hermes,  on  number  of  gynecological  op- 
erations  in  which  the   appendix 
is   affected,   586. 
Hernia,  sacro-pubic,  11,  322. 

ventral,     after     abdominal     operations, 

633. 

Herpes,    buccal,    diagnosis   between,    and 

syphilis    of    the    oro-pharyngeal 

cavity,  422. 

Herpes    progenitalis,    diagnosis    between, 

and  chancre,  402. 
Hessert,  W.,  on  danger  of  perforation  in 

curettage,  189. 
Hildebrandt,    on    ergot    in    treatment    of 

fibroid  tumors,  509. 
Hippocrates,  on  abortion,  452. 
Hirst,  B.  C,  on  age  of  first  menstruation, 
82. 
on  duration  of  menstrual  period,  84. 
on  mechanism  of  menstruation,  ■  80,  81. 
on  method  of  excising  nerves  in  pruri- 
tus, 303. 
on    ovarian    abscess    in    typhoid    fever, 
269. 
Hochsinger,    statistics    by,    of    hereditary 

syphilis,  432. 
Hodgkin's  disease,  amenorrhea  preceding 

and  accompanying,  149. 
Hoffman's  anodyne  for  relief  of  headache, 

235. 
Hofmeier,  on  etiology  of  fibroid  tumors, 
494. 
on  relation  between  fibroid  tumors  and 

heart  disease,  505. 
on  relation  between  fibroids  and  steril- 
ity, 364,  504. 
Hoggan,    on   membranous   dysmenorrhea, 

131. 
Hollister,  C.  G.,  formula  by,  for  relief  of 

backache,  256. 
Hollopeter,  on  education  of  young  moth- 
ers, 42. 
Holt,   L.    E.,   on   vulvo-vaginitis   in   chil- 
dren, 381. 


Home    Economic    Conference,    discussion 

in,  upon  education  of  girls,  42. 
Home,  employment  at,  for  girls,  69. 
Home-making,     importance     of     training 
for,  42. 

Hood's  Sarsaparilla,  percentage  of  alcohol 
in,  114. 

Horseback,  riding  on,  a  cause  of  coccygo- 
dynia,  261. 

Housing  conditions,  necessity  for  im- 
provement in,  45. 

Huber,  on  frequency  of  gonorrhea  among 
prostitutes,  376. 
on  frequency  of  rectal  gonorrhea,  386. 

Huggins,  R.,  on  susceptibility  of  cervix 
to  cancerous  changes  at  time  of 
menopause,  517. 

Hunner,  G.  L.,  case  of  glass  catheter  ex- 
tracted from  the  bladder,  435. 
method  of  cauterizing  cervix,  288,  289, 

374. 
on  hot  bath  in  drainage  of  bladder  in 
cystitis,   559. 

Hunsberger,  on  race  suicide,  347. 

Hunter,  William,  removal  of  largest 
fibroid  tumor  on  record,  488. 

Hunyadi  water  in  constipation,  221. 

Hurdon,  E.,  on  decidual  inflammation  as 
cause  of  abortion,  456. 

Hutchins,  on  artificial  production  of  re- 
nal colic,  617. 

Hutchinson,    Jonathan,    on    syphilis    and 
marriage,  445. 
on   "  syphilitic  imitation,"  417. 

Hyaline  degeneration  of  fibroid  tumor, 
495. 

Hydrargyri,  emplastrum,  442. 

Hydrargyrum     cum  .  creta,     in     primary 
syphilis,  438. 
in  treatment  of  infantile  syphilis,  443. 

Hydrastis  canadensis  in  treatment  of  ute- 
rine hemorrhage,   185,  508. 

Hydrocyanic  acid  for  relief  of  vomiting, 
158. 

Hydronaphthol  in  treatment  of  chlorosis, 
157. 

Hydrosalpinx,  sterility  due  to,  365,  374. 

Hydrotherapy  in  treatment  of  headache, 
232. 
of  splanchnoptosis,  603. 


664 


INDEX. 


Hygiene,  defects  of,  in  schools,  58. 
function  of  physician  in,  41. 
of  infancy  and  childhood,  40. 
of  menstruation,   72. 
of  occupation,  74. 
of  puberty,  67. 
of  school-girl,  51. 
public,  44. 

remedial  measures  in  public,  41. 
Hygienic  measures  in  amenorrhea,  155. 
in  backache,  256. 
in  cancer,  541. 
in  constipation,  217. 
in   dysmenorrhea,   112. 
in  gynecological   affections   in  general, 

30. 
in  headache,  231. 
in  insomnia,  240. 
in  neuroses,  575. 

in  post-operative  convalescence,  622. 
in  prophylaxis  of  abortion,  461. 
of  masturbation,  314. 
of  migraine,  236. 
in  pruritus,  299. 
in  splanchnoptosis,   603. 
in  syphilis,  441. 
in  vaginismus,  306. 
Hymen,   caution   against  injury  to,   112, 
322,  359. 
dilatability  of,  314. 
excision  of,  363. 

imperforate,   method   of   operation  for, 
154. 
primary  amenorrhea  due  to,  145,  151. 
sterility  due  to,  357,  359,  372. 
intact,  in  vaginismus,  304. 
removal  of,  308. 
Hyperthyroidism,  568,  575,  576. 
Hypnotics,  care  in  use  of,  242. 

danger    in    repeating   prescription   for, 
242,  299. 
Hypnotism    in    treatment    of    functional 
neuroses,   585. 
in  treatment  of  insomnia,  241. 
Hypochondria,  568. 

Hypochondrium,  examination  of  right,  7. 
Hyi^oplasia  of  genital  organs.     See  Geni- 
tal organs,  Aplasia  of. 
Hypospadias    a    cause    of   male   sterility, 
352. 


Hyrtl,  on  relation  between  coccygodynia 

and  anchylosis,  264. 
Hysterectomy,  drainage  of  bladder  after, 
vphen  done  for  cancer,  557. 

followed  by  cystitis,  545. 

indications  for,  in  fibroid  tumor,   511. 
Hysteria,  "  accidents  "  in,  566. 

characteristics   of,   566,   573. 

definition  of,  566. 

frequency  of,  566. 

reality  of,  567. 

"stigmata"  in,  566. 

syphilo-toxines  a  cause  of,  397. 

Ichthyol  in  disease  of  upper  bowel,  38. 
in  gonorrhea,  389. 
in  pruritus,  300. 
Heus,  post-operative,  633. 
Ill,  E.  J.,  on  abortion  in  myomatous  ute- 
rus, 456. 
on  frequency  of  abortion  at  menstrual 

periods,  453. 
on  injury  to  cervix  a  cause  of  abortion, 

456. 
on  intra-uterine  injection  of  alcohol  in 

septic  abortion,  471. 
on  number  of  abortions,  453. 
on  operation  during  pregnancy  causing 

abortion,  457. 
on    syphilis   in   causation    of    abortion, 

455. 
on  urethral  dilators  in  mechanical  dila- 
tation of  cervix,  469. 
Imperforate  hymen.     See  Hymen. 
Impetigo  vulgaris,  diagnosis  between,  and 
impetigo  form  of  syphilide,  417. 
Impetigo-form  syphilide,  417. 
Impulses,  abnormal,  570. 
Induration,  syphilitic,  treatment  of,  404. 
Industrial  life,  influence  of,  on  health  of 

women,  74. 
Infancy,  hygiene  of,  40. 
Infant,  syphilis  in,  434,  435,  443. 
Infant  mortality,  41,  44. 
"  Infantilism "     in     hereditary     syphilis, 

435. 
Infection,  cancer  from,  515. 
conjugal,   in  syphilis,  448,  449. 
conveyed  by  instruments,  6,  282. 
death  of  fetus  from,  454,  455. 


INDEX. 


665 


Infection,  fibroid  tumors  caused  by,  494. 

gonorrheal,  of  genital  tract, ;  situations 

most    often    affected,    275,    358, 

376. 

of     urethral     glands.       See     Skene's 

glands, 
of   vulvo-vaginal   glands.      See   Bar- 
tholin's glands, 
infant  mortality  from,  41. 
of  bladder,  after  labor,  480,  555. 
after  operation,  544,  555. 
cause  of  backache,  256. 
precautions  against,  in  catheterization, 

486,  556. 
schools  a  centre  of,  58. 
syphilitic.     See  Syphilis. 
Infectious   diseases,    cause   of   mortality, 
50. 
cause  of  pelvic  disease,  50,  265. 
protection  of  children  from,  50. 
uterine  hemorrhage  during,  271. 
Inflammation  of  pelvic  organs.     See  Pel- 
vic inflammation. 
Ingestion  of  mercury,  438. 

in  infants,  443. 
Injections,  rectal.     See  Enemata. 
Insalivation  of  food,  245,  580. 
Insolation  a  cause  of  headache,  226. 
Insomnia,  238. 

classification  of,  239. 
cold  packs  for,  241,  580. 
drugs  for  relief  of,  242. 
during  rest  cure,  580. 
duty  of  physician  in,  242. 
etiology  of,  238. 
formulae  for,  243. 
frequency  of,  238. 

hygienic  measures  for  relief  of,  240. 
importance  of,  to  gynecologist,  238. 
treatment  of,  239. 
Instillations  of  bladder,  560. 
Instructive  Visiting  Nurses'  Association, 

43. 
Instruments,    infection    conveyed    by,    6, 
282. 
method  of  sterilizing,  6. 
Instruments  required,  for  cystoscopic  ex- 
amination of  bladder,  552. 
for  dilatation  and  curettage,  123. 
for  gynecological  examination,  5. 


Instruments     required,     for     mechanical 

evacuation  of  uterus,  469. 
Intermenstrual  pain,  132. 

absence  of,  during  pregnancy  and  lacta- 
tion, 133,  138. 
age  of  appearance  of,  133. 
character  of,  135. 
date  of  occurrence  of,  134,  139. 
definition  of,  132. 
discharge  with,  135. 
duration  of  attack  of,  135. 
history  of,  132. 
length  of  time  attacks  of,  are  repeated, 

135. 
lesions  associated  with,  135. 
literature  of,  133. 
locations  of,  135. 
relation  of,  to  menstruation,  135. 
relation  of,   to  sterility,  133. 
'    synonyms  for,  132. 

theories  as  to  causation  of,  132,  138. 
treatment  of,  and  its  results,  136. 
value  of  further  reported  cases  of,  139. 
Internal   secretion,   glands   concerned   in, 
disturbances   of,   associated  with 
amenorrhea     and     obesity,     148, 
153. 
Interstitial  hepatitis,  syphilitic,  423. 
Intestine,    inspection    of,    through    head- 
mirror,  36. 
malignant  disease  of,  a  cause  of  consti- 
pation, 215,  222. 
treatment  of  inflamed  area  in,  38. 
Intestines,  alterations  in  position  of,  after 
operations,  632. 
displacement  of.     See  Splanchnoptosis, 
irritation  of  mucosa  of,  a  cause  of  con- 
stipation, 213,  214. 
syphilis  of,  423. 
Intramuscular  injections  of  mercury,  439. 
Intra-uterine  injections  of  alcohol  in  sep- 
tic abortion,  471,  472. 
of  iodoform  and  glycerin,  471. 
of  glycerin,  187,  509. 
Intravenous  injections  of  mercury,  440. 
Inunction,  mercury  by  means  of,  in  in- 
fantile syphilis,  443. 
in  syphilis,  438. 
Inversion  of  uterus.     See  TJtertxs. 
Iodide  of  potash.     See  Potassium. 


666 


INDEX. 


Iodine,  tincture  of,   iu  cancer  of  cervix, 
536. 
in  gonorrheal  infection,  388. 
in  membranous  dysmenorrhea,  131. 
in  syphilis  of  bones,  442. 
Iodoform  and  gelatin  injection  in  septic 

abortion,  471. 
Iodoform  bovigies  in  treatment  of  chan- 
cre, 404. 
Iodoform    gauze    in    tampons,    464,    465, 

466,  469,  476. 
Iodoform  powder,  after  artificial  abortion, 
476. 
after    catheterization    in    the    puerpe- 

rium,  555. 
in    the    dry    treatment    in    gonorrheia, 
389. 
Ireland,  increasing  fertility  in,  347. 
Iritis,  syphilitic,  429. 

Iron,  hypodermic  administration  of,  156. 
tincture  of  chloride  of,  locally,  in  diph- 
theritic vaginitis,  281. 
Irrigation  of  bladder,  597. 

continuous,  564. 
Irritants,  external,  effects  of,  on  local  se- 
verity of  syphilis,  396. 
Isolation  in  treatment  of  functional  neu- 
roses, 577,  578. 
in  treatment  of  insomnia,  242. 
Itching   in   pruritus,   295,   297. 

Jackson's  "  Golden  Seal  Tonic,"  percent- 
age of  alcohol  in,  114. 

Jacobi,  A.,  on  the  administration  of  meth- 
ylene blue  by  mouth  in  treat- 
ment of  uterine  cancer,  538. 

Jacobi,  Mary  Putnam,  on  question  of  rest 
during  menstruation,  73. 

Jacobson,  on  atresia  of  genital  tract  from 
use  of  pessaries,  145. 

Janet,  on  psychasthenia,  669. 

Janitors  in  schools,  necessity  for  training, 
58. 

Jaundice,  pruritus  associated  v?ith,  295. 

Jequirity,  exfoliative  vaginitis  from  use 
of,  281. 

Jewish  race,  tendency  to  obesity  in,  after 
middle  life,  224. 

Johannovsky,  case  of  smallpox  followed 
by  atresia   of  genital  tract,   266. 


Joints,   gonococcus   in   pus   of   inflamed, 
378. 
pains  in,  associated  with  menstruation, 
106. 
associated  with  migraine,  235. 
syphilis  of,  428,  442. 
Joseph,  M.,  on  etiology  of  syphilis,  392. 
Jullien,   on   curability   of   gonorrheal  in- 
fection, 380. 
on  etiology  of  syphilis,  392. 
Jung,  on  gonorrheal  inflammation  of  en- 
dometrium in  little  girls,  269. 
on    treatment    of    functional    neuroses, 
583. 

Kassowitz,    on    statistics    of    hereditary 

syphilis,  432. 
Kehrer,  on  azoospermia,  353. 

on  examination  of  patient  for  sterility, 
369. 
Keith,    on    electricity    in    treatment    of 
fibroid  tumors,  507. 
on    faulty    respiration    as    a    cause    of 
splanchnoptosis,  599. 
Kelly,  H.  A.,  on  examination  of  rectum 
under  air  distention,  34. 
on  production  of  artificial  renal  colic, 
29,  601,  617. 
Kelly's  cylindrical  metal  speculum.     See 

Speculum. 
Keloids,  formation  of,  in  scar  after  lapa- 
rotomy, 632. 
Kemp,    Janet,   on   housing   conditions   in 

Baltimore,  46. 
Keratitis,  syphilitic,  428. 
Kerr,  on  normal  visual  aCuity  in  young 

children,  56. 
Kidney,  anatomy  of,  605. 
backache  in  diseases  of,  251. 
capsules   of,  605. 
normal  mobility  of,  606. 
normal  position  of,  605. 
palpation  of,  7,  609. 
sarcoma  of,  26. 
secondary  infection  of,  by  gonococcus, 

376. 
syphilis  of,  426. 
tuberculosis  of,  548,  550,  557. 
Kidney,   movable,    and   appendicitis,   600, 
612. 


INDEX. 


667 


Kidney,  movable,   artificial  renal  colic  in 
diagnosis  of,  29,  617. 
bandage  for,  618. 
biliary  symptoms  in,  613. 
circulatory  disturbances  in,  613. 
degrees  of  mobility  of,  606. 
diet  in  treatment   of,   618. 
Dietl's  crises  in,  610. 
differential  diagnosis  of,  613. 
etiology  of,    606. 

fecal  accumulation  mistaken  for,  617. 
frequency  of,  608. 
gall-bladder,   distention  of,   mistaken 

for,  614. 
gastro-intestinal  symptoms  of,  611. 
gymnastics  in  treatment  of,  618. 
hematuria   in,   613. 
hysteria  associated  with,  597. 
in  child,  609. 
indications  for  radical  treatment  of, 

619. 
insomnia  accompanying,  239. 
nervous  symptoms  of,   613. 
operations  for,  604,  619. 
pain  in,  610. 

palliative  treatment  of,  618. 
palpation  of,  609. 
pelvic  tumor  mistaken  for,  614. 
pyloric  tumor  mistaken  for,  615. 
renal  calculus  mistaken  for,  616. 
shape  of  body  associated  with,  607. 
suspension  of,  619. 
symptoms  of,  609. 
urinary  symptoms  of,  613. 
vibratory  bimanual  palpation  of,  610. 
Kidney  colic.     See  Renal  colic. 
Kisch,  on  absence  of  sexual  feeling  and 
sterility,  367. 
on  hypertrophy  of  tonsils  and  disorders 

of  menstruation,  57. 
on  obesity  and  sterility,  367. 
Klebs,  on  etiology  of  fibroid  tumor,  494. 

on  etiology  of  syphilis,  392. 
Klein,   on  necessity  for  making  cultures 

of  gonococcus,  385. 
Kleinwachter,  on  abortion  due  to  changes 
in  uterine  ligaments,  456. 
on   atrophy   of   genitalia   in   Basedow's 

disease,  148. 
on  etiology  of  fibroid  tumors,  494. 


Klemperer,  on  cachexia  in  malignant  dis- 
ease, 518. 

Knee-breast  posture.     See  Posture. 

Kneise,  on  curette  in  incomplete  abortion, 
468. 

Knox,  J.  H.  M.,  on  compression  of  ureters 
in  fibroid  tumors,  503. 

Koberle,  case  of  retroflexion  caused  by 
constipation,   33. 

Kocher,  on  Graves'  disease  as  a  cause  of 
amenorrhea,  575. 

Kolischer,  on  nasal  dysmenorrhea,  109. 

Kraus,  on  gonococcus  infection  of  uter- 
ine tubes,  378. 

Krieger,  on  length  of  intervals  between 
the  menstrual  periods,  86. 

Kronig,  on  tissues  affected  by  the  gono- 
coccus, 378. 

Kubinyi,  on  danger  of  intra-uterine  treat- 
ment for  hemorrhage  from 
fibroid  tumors,  509. 

Kussmaul,  on  displacement  of  stomach, 
697. 

Kiistner,  on  gastric  lavage  in  treatment 
of  vicarious  menstruation,  162. 

Labarraque's  solution,  formula  for,  324. 

in  condylomata,  442. 

in  displacements  of  uterus,  323. 

in  inoperable  cancer,  542. 

in  vaginitis,  285. 
Labia,  chancre  of,  400. 

conglutination  of,  144. 

swelling  of,  during  parotitis,  273. 
Labor,    axis-traction   forceps    in   difficult, 
482,  483. 

catheterization  after,  486,  555. 

cause  of  coccygodynia,  261. 

choice  of  nurse  for,  487. 

cystitis  following,  544,  555. 

danger  of  undilated  cervix  in,  482. 

forceps  in,  482. 

gynecological  affections  following,  478. 

infection  following,  478,  479. 

injury  to  cervix  in,  followed  by  cancer, 
517. 

malarial  influence  upon,  271. 

mechanical  injiiries  from,  478. 

methods  of  dilating  cervix  in,  482. 

nervous  exhaustion  after,  478,  480. 


668 


IKDEX. 


Labor,  pathological  sequelte  of,  478. 
pelvimetry  essential  in  difficult,  482. 
pliysiological  sequelas  of,  477. 
precautious    agaiust    cystitis    in,    486, 
555, 
against  infection  in,  482,  488. 
protection  of  perineum  in,  483. 
repair  of  lacerated  cervix  after,  486. 

of  perineum  after,  484. 
sterilized  suit  for  physician  in,  486. 
Laceration  of  cervix,  21,  32,  478, 
cause  of  one-child  sterility,  362, 
repair  of,   after  labor,  486. 
Laceration    of    perineiun,    immediate    re- 
pair of,  484. 
Lactation,  absence  of  intermenstrual  pain 
during,  133,  138. 
prolonged,  cause  of  atrophy  of  genital 
organs,  145. 
Lactic  acid  bacterium,  379. 
Laeto-peptin    in    treatment     of    tertiary 

syphilis,  440. 
Laminaria  tents.     See  Tents. 
Landau,  introduction  of  yeast  treatment 

in  vaginitis  by,  286. 
Lanolin,  in  pruritus,  300, 
Lapland,    age    of    first    menstruation    in, 

83, 
Latero-displacements     of     uterus.        See 

Uterus. 
La  Torre,   on  electricity  in  treatment  of 

fibroid  tumors,  507. 
Laudanum   and  lead-water   in  treatment 
of  pruritus,  301. 
in  treatment  of  vulvitis,  276. 
Laundries,  public,   50. 
Lavage,    gastric,    for   relief    of   headache, 
231. 
in  gastrectasy,  603, 
in  vicarious  menstruation  from  stom- 
ach. 161, 
Lead  poisoning,  abortion  from,  456, 

amenorrhea  from,  149. 
Lebendinsky,  on  changes  in  ovaries  dur- 
ing scarlet  fever,  268,  269,  270. 
Leeches,  application  of,  to  cervix,  159. 
Lefour,  on  iibroid  tumors  in  causation  of 

abortion,  504. 
Lehmann,    on    fibroid   tumors    associated 
vrith  heart  disease,  505. 


Lemanski,    on   malaria   and   pelvic    affec- 
tions, 271,  272. 

Lenharz,  on  the  gonococcus  in  ulcerative 
endocarditis,  378. 

Leopold,  on  changes  in  endometrium  dur- 
ing menstruation,  SO. 
on  chronic  endometritis  as  a  cause  of 

pruritus,  296. 
on  merabranous  dysmenorrhea,  124. 

Leprosy,  diagnosis  between,  and  tubercu- 
lar syphilide,  420. 

Leucoderma  syphiliticum.    See  Syphilide, 
pigmentary. 

Leucomaine   poisoning,   headache   caused 
by,  225. 

Leucoplasia  of  tongTie,  422,  442. 

Leucorrhea.     See  Vaginal  discharge. 

Levaditti,   on  method   of   staining   spiro- 
cheta  pallida,  393, 
on   spirocheta  pallida   in  renal  epithe- 
lium, 398. 

von  Leyden,  on  isolation  of  gonococcus  in 
blood,  378. 
on  presence  of  gonococcus  in  mucous 
membrane,  378, 

Lichen    planus,    diagnosis    between,    and 
miliary  papular  syphilide,  414. 

Lier    and   Ascher,    on    statistics    of   male 
sterility,  354. 

Ligaments,  broad,  induration  of  base  of,  a 
cause  of  abortion,  456. 
induration  of  base  of,  in  prognosis  of 

cervical  cancer,   533, 
tenderness  of,   associated  with  inter- 
menstrual pain,  135. 

Light  and  heat  rays  in  treatment  of  back- 
ache, 258. 
iu  treatment  of  headache,  233. 

von  Limbeck,  on  number  of  red  blood  cor- 
puscles in  chlorosis,  153. 

Lip,  chancre  of,  401. 

Lipomyoma,  496, 

Liquor    sodse    chlorinatse.        See    Labar- 
raque's  solution. 

Liquorice   powder  for   constipation,    220, 
221, 

Lithopedion,  198, 

Liveiug,    E.,    on    causation    of    migraine, 

228, 
Liver,  displacement  of,  601,  604. 


INDEX. 


669 


Liver,  examination  of,  8. 
syphilis  of,  423. 

torpidity   of,    a   cause   of   constipation, 
222. 
a  cause  of  migraine,  236. 
Lobenstein  and  Harrar,  on  birth-rate  of 
babies  with  gonorrheal  mothers, 
378. 
Lochia,  gonococcus  infection  in,  378. 
Loeffler's    bacillus    in    diphtheritic    vagi- 
nitis, 281. 
Lohlein,    on    membranous    dysmenorrhea, 

128. 
Lomer,    on   galvanic   current   in   vaginis- 
mus, 307. 
on  iodide  of  potash,  in  habitual  abor- 
tion, 462. 
on  obesity  as  cause  of  amenorrhea,  148. 
Longstreth's  belt  for  splanchnoptosis,  603. 
Lumbago,  acute,  250. 
Lungs,  syphilis  of,  424. 
Lupus   vulgaris,    diagnosis   between,    and 

tubercular  syphilide,  419. 
Lustgarten,  on  etiology  of  syphilis,  392. 
Lutein  for  functional  amenorrhea,  159. 
for  obesity  accompanied  by  amenorrhea, 

245. 
for  symptoms  associated  with  an  artifi- 
cial menopause,  630. 
with  the  abnormal  menopause,  95. 
Lwoff,  on  atresia  of  genital  tract  due  to 

typhoid  fever,  266. 
Lymph  glands,  induration  of,  in  syphilis, 
358. 
infection  of,  in  gonorrhea,  381. 
Lymphangitis,  accompanying  septic  abor- 
tion, 471. 
in  syphilis,  402. 
Lysol  in  treatment  of  inoperable  cancer, 
536. 

Mackenzie,    J.,    on    nasal    dysmenorrhea, 
109. 

Mackintosh,    Sir  J.,   on  mechanical  dys- 
menorrhea, 107. 

Maclaren,    A.,    on    appendicitis    and   dys- 
menorrhea, 592. 
on  appendicitis  and  salpingitis,  590. 

MacMonagle,  B.,  on  syphilis  as  a  cause  of 
uterine  hemorrhage,  180. 


"  Macula)  gonorrhoicse,"  359,  385. 
Madlener  and  Menge,  on  the  gonococciis 

in  uterine  muscle,  378. 
Magnesium   sulphate.      See   Saline  laxa- 
tives. 
Malaria,    influence    of,    in    causation    of 
amenorrhea,  148. 
in  causation  of  headache,  226,  233. 
in  convalescence  from  gynecological 

operations,  634. 
on  labor,  271. 
on  menstruation,  271. 
on  ovarian  neuralgia,  272. 
on  pelvic  disease  in  general,  271. 
on  pregnancy,  271. 
on  puerperium,  271. 
Maldevelopment  of  genital  organs,  cause 
of    amenorrhea,    140,    147,    150, 
154. 
cause  of  dysmenorrhea,  108,  120. 
cause  of  sterility,  256,  360,  363,  365. 
Malformations  in  infantile  syphilis,  436. 
Malignant  disease  of  intestine,  a  cause  of 
constipation,  215,  222. 
examination  for,  38. 
Malnutrition,  causes  of,  41. 
infant  mortality  from,  41. 
Mammary    gland,     swelling     of,     during 
parotitis,  273. 
syphilis  of,  427. 
Mandl,  on  the  gonococcus  in  submucous 

tissues,  378. 
Manganese,    as   an  emmenagogue,   160. 

in  chlorosis,  157. 
Mangelsdorf,  on  migraine  associated  with 

dilatation  of  stomach,  228. 
Manias,  mental,  in  psychasthenia,  571. 
Mantegazza,  on  marriage  of  cousins  and 

sterility,  368. 
Manual    reduction    of    uterus,    in    preg- 
nancy,  322,   462. 
method  of,  326. 
Marienbad,  treatment  of  obesity  at,  246. 
Marriage   between    relatives    a    cause   of 
sterility,  368. 
gonorrhea  and,  384. 
interval    between,    and    birth    of    first 

child,  350. 
period  after,  at  which  sterility  presum- 
ably begins,  349. 


670 


INDEX. 


Marriage,    relative   sterility    of    wives    at 
different  epochs  in,   341). 
syphilis  and,  443. 
Martin,  on  fatty  degeneration  of  fibroid 

tumors,  496. 
Maslovski,  on  experiments  on  gonotoxine, 
379. 
on  gonococcus  in  placenta  and  decidua, 
378. 
Massage  in  backache,  256. 
in  coccygodynia,  263. 
in  constipation,  221,  223. 
in  insomnia,   241. 
in  movable  kidney,  617. 
in  palliative  treatment  of  gynecological 

affections,   31,    32. 
in  pelvic  inflammation,  343. 
in  post-operative  phlebitis,  631. 
in  rest  cure,  581. 
in   splanchnoptosis,    603. 
of     uterus     in     incomplete      abortion, 
467. 
Massin,  on  inflammation  of  uterus  due  to 

infectious  disease,  269,  270. 
Mastication,  importance  of,  580. 

in  treatment  of  obesity,  245. 
Masturbation,  309. 

a  cause  of  fibroid  tumors,  494. 

a  cause  of  pruritus,  296. 

a  cause  of  vaginismus,  296. 

clinical  findings  in,  312. 

constitutional  causes  of,  310. 

curative  treatment  of,  315. 

diagnosis  of,  314. 

effects  of,  314. 

general  considerations  affecting,  309. 

in  animals,   309. 

local  causes  of,  310. 

methods  of,  311. 

periods    of    life    when   most   frequent, 

309. 
prevalence  of,  310. 
prophylaxis  of,  314. 
time  of,  312. 
Maternity,   education  of  women  for,   40, 

41. 
Mathes,    on   etiology    of    splanchnoptosis, 

599. 
Mayer,  L.,  case  of  typhoid  fever  followed 
by  atresia  of  genital  tract,  266. 


McNaughton,  case  of  ovarian  metastasis 
during  parotitis,   272,   273. 
case    of    swelling    of    mammary    gland 
during  parotitis,   273. 
Measles,  abortion  caused  by,  455. 

atresia  of  genital  tract  caused  by,  267. 
Meatus    urinarius,    character    of    chancre 
upon,  400. 
protection  of,  by  the  labia  urethrse,  380. 
Mechanical  amenorrhea,  145,  152. 

treatment  of,  153. 
Mechano-therapy  in  treatment   of   sacro- 

lumbar  rheumatism,  258. 
Medical  inspection  of  schools,  54. 
Medicine   in  general  treatment   of  gyne- 
cological affections,  30. 
Meigs,     on    pruritus    due    to    trichiasis, 
301. 
on  pruritus  during  pregnancy,  303. 
Melancholia   at    an    artificial   menopause, 

628. 
Melchior,  on  the  gonococcus  in  the  urine 

of   cystitis,   378. 
Membranous    dysmenorrhea.       See    Dys- 
menorrhea. 
Meningitis,  headache  caused  by,  226. 
Menopause,  87,  244,  245. 
age  of,  89. 
abnormal,  95. 

artificial,  menstruation  after,  79,  629. 
production  of,  for  dysmenorrhea,  ob- 
jections to,  126. 
symptoms  of,  628. 
treatment  of,   630. 
carcinoma  of  uterus  at,  96,  517. 
hemorrhage  from  uterus  at,  98,  520. 
local  changes  in  genitalia  at,  90. 
obesity  at,  244,  245. 
pregnancy  in,  91. 
premature,  80. 
pruritus  at,  296. 
symptoms  of,  90. 
vaginal  discharge  at,  520. 
Menorrhagia.       See     Hemorrhage     from 

uterus. 
Menstrual        molimina,        accompanying 
amenorrhea,   150,   151,   159. 
constancy  of,  106. 
definition  of,  105. 
nature  of,  105. 


INDEX. 


671 


Menstrual   molimina,    relief    of,    in    sup- 
pressed menstruation,  159. 
Menstrual    periods,     abortion    most    fre- 
quent at  dates  corresponding  to, 
453,  462. 

amount  of  ilow  during,  85,  163. 

bath  during,  72. 

character  of  flow  during,  82. 

duration  of  flow  during,  83,  85. 

excess  of  flow  during,   associated  with 
excess  of  duration,  84. 

excessive.        See      Hemorrhage      from 
Uterus. 

exercise  during,  73. 

gonorrheal  infection  most  frequent  at, 
384. 

interval  between,  85. 

local  symptoms  at,  105. 

migraine  at,  236. 

pain  during.     See  Dysmenorrhea. 

pruritus  after,  296,  299. 

reflex  symptoms  at,  106. 

rest  during,  73. 

in  post-operative  convalescence,  627. 

sacro-iliac  joints  relaxed  at,  252. 

variations  of,  at  puberty,  86. 
Menstruation,  age  of  first,  82,  83,  147. 

among  aboriginal  people,  105. 

cancer  of  uterus  in  relation  to,  517. 

cessation  of.     See  Menopause. 

changes  in  genitalia  during,  80. 

college  life  in  relation  to,  77. 

conception  in  absence  of,  79. 

continuance  of,   after  removal   of   ova- 
ries, 79,  629. 

corpus  luteum  in  relation  to,  80,  139. 

definition  of,  78. 

hereditary     influence     in     determining 
first  appearance  of,  83,  145. 

hygiene  of,  72. 

intermenstrual  pain  in  relation  to,  135. 

mechanism  of,  80. 

neurasthenia  in  disturbances  of,  568. 

ovulation  in  relation  to,  78. 

painful.     See  Dysmenorrhea. 

precocious,  82. 

profuse.     See  Hemorrhage  from  uterus. 

proportion  of  woman's  life  covered  by, 
87. 

school-life  in  relation  to,  66. 


Menstruation,  suppression  of.    See  Amen- 
orrhea, 
theories  of,  78. 
vicarious,  160. 
definition  of,  160. 
etiology  of,  161. 
heredity  in,  161. 
situations  of,  160. 
treatment  of,  161. 
varieties  of,  160. 
Mental  development  influenced  by  heredi- 
tary syphilis,  435. 
Menthol  douche,  384,  331. 

powder,  284. 
Mercurial  stomatitis,  422. 
Mercuric  baths,  in  treatment  of  infantile 

syphilis,  443. 
Mercury,  bichloride  of,  in  chancre,  404. 
in  diphtheritic  vaginitis,  281. 
in  disinfection  of  pessaries,  325. 
in  preparation  of  sterile  gauze,  466. 
in  preparation  of  sterile  towels,  465. 
in  prevention  of  abortion,  461. 
in  treatment  of  infantile  syphilis,  443. 
methods   of  administering,  in  syphilis, 
dermic,  442. 
dermo-pulmonary,  439. 
hypodermic,  439. 
intramuscular,  439. 
intravenous,  440. 
ingestion,  438. 
inunction,  438. 
for  infantile,  439. 
principal  preparations  of,  employed  in 
treatment    of    syphilis,    acid    ni- 
trate, 442. 
ammoniate  of,  ointment,  442. 
benzoate  of,  439. 

bichloride.       See     Mercury,     bichlo- 
ride of. 
blue  ointment,  442,  443. 
cacodylate,  439. 
calomel,  439,  442,  443. 
Dupuytren's  pills,  439. 
gray  oil,  439. 

hydrargyrum  cum  creta,  438. 
oleate,  443. 
oleate   ointment,  442. 
protoiodide   pills,   438. 
salicylate,   438,  439. 


672 


INDEX. 


Mercury,   principal   preparations    of,   em- 
ployed in   treatment  of  syphilis, 
salicylo-arsenate,  439. 
tannate,  438. 
white  precipitate,  442. 
principles     of     administration     of,     in 
syphilis,  437. 
Metastases  to  genital  organs  in  parotitis, 

272. 
Methylene  blue  in  treatment  of  cystitis, 
559. 
of  gonorrhea,  388. 
of  iiterine  cancer,  locally,  537. 
by  mouth,  538. 
Metrorrhagia.       See     Hemorrhage     from 

uterus. 
Mewes,   on  statistics  of  hereditary  syph- 
ilis, 432. 
Meyer,  W.,  on  methylene  blue  in  the  treat- 
ment of  inoperable  cancer,  537. 
Michaelis,  on  isolation  of  gonococcus  in 

blood,  378. 
Mickle,  on  psychasthenia,  569. 
Microscopic  examination,  in  cancer,  525. 
in  cystitis,  548,  549. 
in  gonorrheal  infection,  385. 
in  pelvic  inflammation,  339. 
in  vaginitis,  280. 
in  vulvitis,  276. 

method  of  preparing  slides  for,  276. 
method  of  preparing  urine  for,  548. 
Micturition.     See  Urination. 
Midwives,  duty  of,  in  prophylaxis  of  can- 
cer, 531. 
harm  done  by  careless,  487. 
Migraine,  acute  dilatation  of  stomach  in, 
228. 
at  menstrual  periods,  236. 
clinical  history  of,  235. 
dizziness  in,  235. 
duration  of  an  attack  of,  236. 
etiology  of,  228. 
gastric     disturbance     associated     with, 

236. 
giddiness   in    237. 
heredity  in  causation  of,  225. 
prodromic  symptoms  of,  235. 
.  prophylaxis  of,  236. 
psychic  disturbances  in,  235. 
relation  of,  to  epilepsy,  228. 


Migraine,  situation  of  pain  in,  235. 
treatment  of,  236. 

uremic  poisoning  in  causation  of,  237. 
vaso-motor  disturbances  in,  228,  236. 
Milk,  in  rest  cure,  579. 

Walker-Gordon,  45. 
Milk  Commissions,  45. 
Milk  supply,  public  control  of,  essential  to 

health  of  community,  44. 
Millspaugh,  W.  P.,  on  association  between 
migraine  and  disturbance  of  gas- 
tric secretion,  229. 
Mind,   distress   of,   a   cause  of   headache, 
227. 
a  cause  of  insomnia,  242. 
power  of,  over  body  in  gynecological  af- 
fections, 31. 
use    of,    in   treatment    of   functional 
neuroses,  582. 
Mirror,  head,  in  examination  of  bladder, 
552. 
of  rectum,  35. 
Mitchell,  Weir,  on  rest  cure,  577,  578. 
Mittelsclimerz,  132. 
Mixed  chancre,  400. 
Mixed  infection  in  gonorrhea,  379. 
Mobius'  sign,  576. 

Montgomery,    on   age   of   first   menstrua- 
tion, 82. 
on  age  of  menopause,  87. 
on  duration  of  menstrual  period,  84. 
Moore,  T.  M.,  on  duty  of  the  state  to  pro- 
vide   sufficient    food    for    school 
child,  56. 
Morgagni,  on  displacement  of  abdominal 
viscera,  597. 
on  membranous  dysmenorrhea,  128. 
Morphin,    habitual    use    of,    a    cause    of 
amenorrhea,  149. 
in  coceygodynia,  264. 
in  dysmenorrhea,  116. 
in  migraine,  236. 
in  inoperable  cancer,  542. 
in  renal  colic,  619. 
in  vulvitis,  277. 
Morphin  habit.     See  Opium. 
Morris,  R.  T.,  on  importance  of  abdomi- 
nal rigidity  in  diagnosis  between 
acute  appendicitis  and  salpingi- 
tis, 590. 


INDEX. 


673 


Morrow,   P.    A.,    on   professional    secrecy 

with  syphilitic  patients,  447. 
Morse,    Elizabeth,    on    membranous    dys- 
menorrhea, 128,  foot-note. 
Mortality,  from  infectious  diseases,  50. 
from  nephrorrhaphy  in  movable  kidney, 

620. 
from  radical  operation  for  fibroids,  512. 
in  children  from   external   conditions, 

41. 
in  fibroid  tumors,  505. 
infant,  causes  of,  41. 

decrease  of,  in  New  York  from  im- 
provement in  public  hygiene,  44. 
Mosetig-Moorhof,    on   methylene   blue    in 
treatment  of  uterine  cancer,  537. 
Mossmann,    on    atresia    of    genital    tract 

from  infectious   disease,   265. 
Mother,  abortion  due  to  causes  in,  455. 
education  of,  40,  41. 
relation  of,  to  child  in  syphilis,  433. 
specific     treatment    of,     in    hereditary 
syphilis,  443. 
Motion,   disturbances   of,   in  appendicitis 
in  child,  596. 
in  treatment   of   sacro-lumbar  rheu- 
matism, 257. 
Motor  system,  syphilis  of,  427. 
Moullin,    on   movable   kidney   simulating 

gastric  ulcer,  612. 
Mouth,  hygiene  of,  in  syphilis,  441,  442.    • 

syphilis  of,  421. 
Movable  kidney.     See  Kidney. 
Mucous  patches,  421,  449. 

treatment  of,  442. 
Multiparas,  frequency  of  abortion  in,  453. 
Mumps.     See  Parotitis. 
Muscles,        abdominal,        exercises       for 
strengthening,  218,  232. 
massage  of,  221,  223. 
weakness  of,  a  cause  of  constipation, 
213. 
lumbar,    ironing    of,    in    treatment    of 

lumbago,  250. 
rheumatism  of,  251,  256. 
syphilis  of,  427. 
Mustard  baths  in  dysmenorrhea,  116. 
Mustard  plasters  on  back  of  neck,  for  re- 
lief of  headache,  127. 
for  relief  of  migraine,  132. 
U 


Mustard  plasters  on  spine  for  dysmenor- 
rhea, 116. 

Myocarditis  due  to  syphilis,  425. 

Myomata.     See  Fibroid  tumors. 

Myomectomy,  reasons  for  choice  of,  in 
fibroid  tumors,  511. 

Myopia  in  school  children,  57. 

Myxedema,  obesity  associated  with,  248. 

Myxomatous  degeneration  of  fibroid  tu- 
mors, 496. 

Nabothian  follicles,  287,  525. 
Nagel,  on  atresia  of  vagina  caused  by  in- 
fectious disease,  265. 
Nails,  syphilis  of,  420. 
Naphthalin,    in    treatment    of    pruritus, 

300. 
Napoleon,  family  history  of  cancer,  515. 
Nasal  dysmenorrhea,  109. 
Naso-pharynx,  syphilis  of,  424. 
Nauss,  on  fibroid  tumors  a  cause  of  abor- 
tion, 505. 
Necrosis  of  fibroid  tumors,  496,  502. 
Necrospermia   a   cause   of  male   sterility, 

352,  369. 
Negroes,  frequency  of  fibroid  tumors  in, 

493. 
Neisser,  discovery  of  gonococcus  by,  351, 
375. 
on  abortive  treatment  of  chancre,  404. 
on  inoculation  of  monkeys  with  syph- 
ilis, 432,  436. 
Nephrectomy  for  movable  kidney,  621. 
Nephritis,  chronic,  amenorrhea  in,  148. 
chronic  syphilitic,  426. 
contraindication      to      operations      for 

fibroids,   511. 
headache  from,  225,  226. 
migraine  from,  237. 
pruritus  from,  396. 
sterility  associated  with,  360. 
Nephropexy    for    movable    kidney,     620, 

621. 
Nephrorraphy   for   movable   kidney,    619, 

620. 
Nerve  centres,  lesions  of,  due  to  syphilis, 

446. 
Nerves  to  the  eye,  syphilis  of,  428,  429. 
Nervine,   anti-,  treatment  for"  syphilis  in 
neurasthenic  patients,  441. 


674 


INDEX. 


Nervous  exhaustion  after  labor,  478,  480. 

headache  from,  226. 
Nervous  headache,  225,  228. 
Nervous  system,  exhaustion  of.    See  Neu- 
rasthenia, 
syphilis  of,  430. 
Neugebauer,   on   atresia   of  genital  tract 
caused    by    infectious    diseases, 
266. 
Neuralgia,  associated  v^ith  coccygodynia, 
262. 
of  ovary,  influenced  by  malaria,  272. 
Neurasthenia,  backache  in,  241, 
characteristic  of,  567,  573. 
circulatory  symptoms  of,  567. 
digestive  symptoms  of,  567. 
dysmenorrhea  in,  109,  365,  567,  592. 
etiology  of,  568. 
fatigability  in,  567,  573. 
frequency  of,  567. 

genito-urinary  symptoms  of,  568,  569. 
headache  in,  225,  226,  228,  567. 
insomnia  in,  238,  239,  567,  581. 
retrodisplacement  of  uterus  a  cause  of, 

320. 
spinal  pain  in,  226. 
splanchnoptosis  associated  with,  599. 
syphilo-toxines  a  cause  of,  397. 
Neurologist,   reasons   for   cooperation   of, 

with  gynecologist,  573. 
Neuropathic    constitution    influenced    by 

syphilis,  441,  446. 
Neuropathic  patients,  treatment  of  syph- 
ilis in,  441. 
Neuroses,    associated  with   syphilis,    396, 
397,  430,  441,  446. 
cause  of  pruritus,  295,  296,  299. 
functional,  abnormal  impulses  of,  570. 
after  oophorectomy,  629. 
diagnosis  of,  572. 
diet  in  treatment  of,  579. 
emotional  training  in,  584. 
etiology  of,  568. 
hyperthyroidism  in,  581. 
hypnotic  suggestion  in  treatment  of, 

585. 
hypochondria,  568. 
hysteria,  566. 

isolation  in  treatment  of,  578. 
massage  in  treatment  of,  581. 


Neuroses,    functional,    medical    obedience 
in  treatment  of,  583. 
neurasthenia,  567. 
nurse  in,  584. 
obsessions  in,  570. 
persuasion  in  treatment  of,  583. 
prognosis  of,  576. 
psychasthenia,   569. 
psycho-therapy  in  treatment  of,  582. 
re-education  in  treatment  of,  582. 
suggestion  in  treatment  of,  583. 
traumatic,  568. 
treatment  of,  576. 
types  of,  566. 
varieties  of,  566. 
Neurotic  dysmenorrhea,  108. 
Newsholme  and  Stevenson,  on  reasons  for 

decline  in  population,  347. 
van    Niessen,     on     etiology     of    syphilis, 

392. 
Night,  habit  of  working  in,  a  cause  of  in- 
somnia, 238. 
Niot,  on  dermoid  cyst  with  twisted  pedi- 
cle   mistaken    for     appendicitis, 
590. 
Nitre,  sweet  spirits  of,  in  cystitis,  559. 
Nitroglycerin,  for  headache  with  high  ar- 
terial tension,  233. 
Noble,  on  degeneration  of  fibroid  tumors, 
473,  495,  496,  497. 
on  disease  of  uterine  appendages  associ- 
ated with  fibroid  tumors,  497. 
on   fibroid   tumors    and    heart    disease, 

505. 
on  mortality  in  myomectomy,  512. 
Nocturnal  headache  due  to  syphilis,  226, 

430. 
Noeggerath,  on  the  gonococcus  as  a  cause 

of  sterility,  250,  375. 
von   Noorden's   system    of  treatment   for 

obesity,  248. 
Norway,  increased  fertility  in,  347. 
Nose,  condition  of,  in  school-girls,  57. 
mucous   membrane    of,    gonococcixs    in, 
360. 
syphilis  of,  424,  442. 
Nosophobia,  568. 

Nott,  J.  C,   on  atresia  of  vagina  in  in- 
fants, 144. 
on  coccygodynia,  261,  262,  263. 


INDEX. 


675 


Nulliparae,   rarity   of   cervical   cancer   in, 

169,  362,  517. 
Nurse,  choice  of,  in  labor,  487. 
in  inoperable  cancer,  542. 
in  rest  cure,  579. 

in  treatment  of  functional  neuroses, 
584. 
office,  3. 
school,  58. 

wet,  specific  treatment  of,  in  hereditary 
syphilis,  443. 
syphilitic   infection    conveyed    to,    or 
received  from,  nursling  by,  399. 
Nutrition,  at  puberty,  67. 

defective,     a     cause     of     ill-health     in 

school-girls,  55. 
impairment  of,  by  constipation,  207. 
importance  of,  to  education  of  children, 
56. 
Nux  vomica,  for  backache,  256. 
for  constipation,  220. 
for  headache,  232. 
in  inoperable  cancer,  538. 
in    post-operative    convalescence,.   624, 
627. 

Obedience,  importance  of,  in  treatment  of 

neuroses,  583. 
Obesity,  amenorrhea  associated  vpith,  148, 
208,  245. 

blood,  changes  in,  accompanying,  244. 

definition  of,  244. 

diet  in,  246. 

diet  lists  for,  246,  247. 

disturbance  of  internal  secretions  asso- 
ciated vpith,  148. 

etiology  of,  224. 

heart,  changes  in,  caused  by,  224. 

heredity  in  causation  of,  224. 

prophylaxis  of,  248. 

Spa  treatment  of,  246. 

sterility  associated  vs^ith,  245,  331. 

symptoms  of,  244. 

synonyms  for,  244. 

systems  of  treatment  of,  248. 

thyroid  gland  in  treatment  of,  248. 

treatment  of,  245. 
Obsessions,  570. 
Obstetric  forceps,  rules  for  use  of,  582. 

gown,  487. 


Obstetrician,  duty  of,  482,  486. 
Occupation,  hygiene  of,  74. 

sedentary,  a  cause  of  constipation,  213. 
Occupation  therapy  in  post-operative  con- 
valescence, 625. 
in    treatment    of    functional    neuroses, 
585. 
Ochsner,    on    dysmenorrhea    and    chronic 

appendicitis,  592. 
Oertel's  system  for  treatment  of  obesity, 

248. 
Office,  arrangements  of,  2. 

nurse  in,  3. 
Oil,  cod-liver,  155,  233,  245. 
locally,  300. 
cotton-seed,  222. 
of  pennyroyal,  456. 
sweet,  221,  298. 
Ointment,  belladonna,  404. 
blue,  442,  443. 
benzoated,  301. 
carbolic  acid,  300. 
cocain,  300. 
thymol,  301. 
Ointments,  mercurial,  304,  442,  443. 
Old  age,  cancer  of  clitoris  and  vulva  in, 
636. 
of  uterus  in,  638. 
pruritus  in,  636. 
pyokolpos,    pyometra    and    physometra 

in,  639. 
tumor  in,  fibroid,  640. 
of  urethra,  636. 
ovarian,  640. 
vagina  in,  atrophy  of,  637. 

hypersensitive  orifice  of,  637. 
vaginitis  in,  637. 
Oligospermia,    male    sterility    from,    352, 

353,  372. 
Oliver,  on  atrophy  of  chorionic  villi,  455. 
Olshausen,   on  fibroid  tumors   and  steril- 
ity, 363,  505. 
on  injury  to  cervix  a  cause  of  abortion, 

456. 
on  nitrate  of  silver  in  treatment  of  pru- 
ritus,  302. 
on  septic  abortion  due  to  criminal  in- 
terference, 460,  470. 
One-child  sterility,  definition  of,  347. 
due  to  atresia  following  labor,  260. 


676 


I]S"DEX. 


Oue-cliild    sterility,    due    to    atrophy    of 
uterus  after  laboi%  366. 
due  to  gonoeoccus  infection,  384. 
due  to  retroiiexion  after  labor,  363. 
Onychia,  syphilitic,  421. 
Oophorectomy.     See  Ovaries,  removal  of. 
Operation,  Alexander,  332. 
backache  after,  251,  260. 
convalescence  from.    See  Post-operative 

convalescence, 
cystitis  following,   544. 
during  pregnancy,  a  cause  of  abortion, 

487. 
for  dilatation  and  curettage,  123,  189. 
for  imperforate  hymen,  154. 
for  lacerated  cervix,  32,  486. 
for  redundant  sigmoid  in  cure  of  con- 
stipation, 213. 
for    retrodisplacement    of    uterus,    332, 

333. 
radical,    for    cancer,    contraindications 
to,  633. 
importance    of   early,    169,    520,   530, 
532. 
indications  for,  532. 
for  fibroid  tumor,  choice  of,  511. 
contraindications  to,  511. 
indications  for,  506,  510. 
mortality  from,  512. 
time  for,  512. 
Operations,  abdominal,  alterations  in  po- 
sition of  intestines  after,  632. 
care  of  bowels  after,  222. 
constipation  after,  208,  625. 
enlargement  of  scar  after,  632. 
fermentation      in     lower     intestines 

after,  227. 
hernia  after,  633. 
ileus  after,  633. 

suppuration  of  wound  after,  631. 
tenderness  of  scar  after,  632. 
Operative  treatment  in  amenorrhea,  154. 
in  cervicitis,  288. 
in  coccygodynia,  263. 
in  dysmenorrhea,  120. 
in  endometritis,  294. 
in  extra-uterine  pregnancy,  206. 
in  movable  kidney,  619. 
in  pelvic  inflammation,  344. 
in  pruritus,  302. 


Operative   treatment    in    splanchnoptosis, 
604. 
in  sterility,  372. 
in  uterine  hemorrhage,  188. 
in  vaginismus,  308. 
in  vulvitis,  277. 
Ophthalmia,  gonorrheal,  prevention  of,  386. 
Opium  habit,  cause  of  amenorrhea,  152. 
cause  of  sterility,  367. 
cure  of,  during  post-operative  convales- 
cence, 626. 
risk  of,  in  coccygodynia,  264. 
in  dysmenorrhea,   177. 
in  insomnia,  242. 
Opium  in  dysmenorrhea,  117. 
in  gonorrhea,  386. 
in  imminent  abortion,  462. 
in  inoperable  cancer,  541,  542. 
in  renal  colic,  619. 
Oppenheim,  on  individual  endeavor,  52. 
Oppolzer,  on  hysteria  and  floating  kidney, 

597. 
Opsonic  treatment  in  cystitis,  562. 
Optic  nerve,  syphilis  of,  429. 
Oral  cavity,  gonoeoccus  in  mucous  mem- 
brane of,  378. 
Orchitis,  syphilitic,  425. 

treatment  of,  443. 
Oro-pharyngeal  cavity,  syphilis  of,  421. 
Orth,  case  of  atresia  of  genital  tract  fol- 
lowing diphtheria,  267. 
Osier,  on  atony  of  colon,  causing  consti- 
pation, 213. 
on  explanation  of  Dietl's  crises,  610. 
on  nux  vomica  in  increasing  doses,  624. 
on  tumor  of  pylorus  simulating  mova-- 
ble  kidney,   615. 
Osteo-arthritis,  cause  of  backache,  256. 
of  vertebrae,  misleading  symptoms  asso- 
ciated with,  574. 
Osteomyelitis,  syphilitic,  428. 
Osteoscopic  pains  in  syphilis,  394. 

treatment  of,  442. 
Ovarian    adhesions,    association    of,    with 
sterility,  358,  366. 
formation   of,    in   pelvic    inflammation, 
341. 
Ovarian  dysmenorrhea,  110. 
Ovarian  extract,  at  menopause,  95. 
for  intermenstrual  pain,  136. 


INDEX. 


677 


Ovaries,  amenorrhea  from  aplasia  of,  141, 
147,  150. 
atropliy  of,  in  exhausting  diseases,  268. 
bimanual  examination  of,  11. 
cystic  enlargement  of,  a  cause  of  ute- 
rine hemorrhage,  176. 
hyperesthesia  of,   in  functional   neuro- 
ses, 565. 
hypertrophy  of,  in  chlorosis,  147. 
infantile,  141,  147,  150. 
inflammation  of,  in  infectious  diseases, 

268. 
irritation  of,  a  cause  of  masturbation, 

310. 
mobility  of,  12. 

metastases  to,  in  parotitis,  272. 
normal,    removal    of,    for    amenorrhea 
with  menstrual  molimina,  155. 
for  dysmenorrhea,  126. 
for  vicarious  menstruation,  162. 
menstruation  after,  79,  629. 
obesity  following,   244. 
symptoms  associated  with,  629. 
vaginitis  following,  282. 
pain  in,  associated  with  malaria,  272. 
physiological  changes  in,  possibly  asso- 
ciated with  intermenstrual  pain, 
132,  138. 
sterility    associated    with    maldevelop- 

ment  of,  365,  372. 
syphilis   of,   427. 
Ovaritis,  chronic,  and  dysmenorrhea,  109. 
Ovary,  abscess  of,  associated  with  septic 
abortion,  471. 
cause  of  sterility,  366. 
in  typhoid  fever,  269. 
cyst  of,  diagnosis  between,  and  pedun- 
culate cystic  myoma,  499. 
disease  of,  mistaken  for  disease  of  rec- 
tum, 33. 
gonococciTS   infection   in   substance   of, 

378. 
prolapse    of,    associated    with    retrodis- 

placement  of  uterus,  320. 
tumor  of,  and  appendicitis,  588. 
bimanual  examination  of,  15. 
diagnosis  between,  and  retrodisplace- 

ment  of  uterus,  322. 
in  child,  26. 
permanent  record  of,  on  gauze,  18. 


Ovary,    tumor    of,    precocious    menstrua- 
tion associated  with,  82. 
rectum  choked  by,   33. 
sterility  caused  by,  366. 
Ovary  and  tube,  removal  of,  on  one  side 
for  relief  of  intermenstrual  pain, 
136,  137. 
Overcrowding    a    cause    of    mortality    in 

children,  45. 
Ovulation,   relation   of,    to   menstruation, 

78. 
Ovum,    attachment    of,    in    extra-uterine 
pregnancy,  194. 
causes  of  abortion  due  to,  454. 
influence  of  corpus  luteum  upon,  79. 
Ozena  syphilitica,  424. 

Packs,    cold,   for   relief   of   insomnia,   32, 
241,  580,  581. 
hot,  for  relief  of  insomnia,  32,  581. 
vaginal.     See  Tampons. 
Pad  in  sacro-iliac  rheumatism,  259. 

in  splanchnoptosis,  603. 
Pain,  habit  of,  626. 
post-operative,  626. 
production    of    renal,    for    purposes    of 

diagnosis,  29,  617. 
significance  of,  in  gynecological  exami- 
nation, 27,  29. 
symptom     of    cancer,     169,     518,     519, 
531. 
of  cystitis,  548. 
of  movable  kidney,  610. 
of  pelvic  inflammation,  337. 
Paine's  Celery  Compound,  percentage  of 

alcohol  in,  114. 
Palmar  and  plantar  syphilides,  415. 
Palpation,  abdominal  method  of,  in  gyne- 
cological examination,  7. 
in  movable  kidney,  609,  610. 
Pancoast,  H.  K.,  on  splanchnoptosis,  597, 
598. 
on  X-ray  in  treatment  of  uterine  can- 
cer, 537. 
Pancreas,  syphilis  of,  424. 
Papulitis,  syphilitic,  429. 
Paraffin,  injection  of,  in  chronic  cystitis, 

564. 
Paralysis,    general,    syphilitic,    397,    430, 
437. 


678 


INDEX. 


Paralysis  of  nerves  to  eye,  from  syphilis, 

428,  429. 
Parasitic   diseases,  prevalence   of,   among 

school-children,  58. 
Parasyphilis,  396. 

Parks,  public,  beneficial  effect  of,  49. 
Parotid    gland,    enlargement    of,    during 
pregnancy,  273. 
for  intermenstrual  pain,  136. 
Parotitis,  metastases  during,  to  sexual  or- 
gans, 272. 
Paronychia,  syphilitic,  421. 
Parsons,    Mrs.,    on    state    supervision    of 

home  education,  43. 
Parsons,  J.  E.,  on  electricity  in  treatment 

of  uterine  hemorrhage,  188. 
Parturition.     See  Labor. 
Patent  medicines,   percentage   of   alcohol 

in,  114. 
Pediculus    pubis,    pruritus    due    to,    296, 

298. 
Pellanda,  C,  on  fibroid  tumors,  505. 
Pelvic  abscess,  incision  of,  through  vagi- 
nal vault,  342. 
rectum  choked  by,  33. 
Pelvic  circulation,  disturbances  of,  caus- 
ing hemorrhoids,  33. 
stasis  of,  inducing  constipation,  208. 
Pelvic   disease,   acute   infectious   diseases 
the  cause  of,  50,  265. 
appendicitis  associated  vpith,  586. 
coccygodynia  associated  with,  262. 
influence  of  malaria  upon,  271. 
masturbation  caused  by,  310. 
Pelvic    inflammation,    appendicitis    with, 
587,  589. 
conservatism  in  treatment  of,  344. 
definition  of,  335.   . 
diagnosis    between,     and    appendicitis, 

340,  589. 
diagnosis  of,  337. 
dysmenorrhea  with.  111,  337,  338. 
etiology  of,  336. 
examination  in,  339. 
exppctant  treatment  of,  342. 
fever  in,  338. 

fibroid  tumors  complicating,  497,  505. 
gonocoecus  infection  in,  341. 
infective,  335. 
local  signs  of,  339. 


Pelvic     inflammation,     menstruation    af- 
fected by,  177,  337. 
non-infective,  335. 
non-sensitive,  337. 
opening  abscess  in,  342. 
palliative  treatment  of,  343. 
puerperal  infection  in,  339. 
radical  treatment  of,  344. 
sensitive,  337. 
sterility  caused  by,  365. 
symptoms  of,  367. 
tubercular,  369. 
varieties  of,  366. 
Pelvic  tumor,  cancer  of  rectum  mistaken 
for,  34. 
constipation  caused  by,  222. 
diagnosis  between,  and  movable  kidney, 
614. 
Pelvimetry,  482. 
Pelvis,  syphilis  of,  427. 
Pemphigus,  presence  of,  at  birth  a  sign 

of  hereditary  syphilis,  434. 
Penrose,   C.  B.,   on  acute   infectious  dis- 
eases in  the  causation  of  pelvic 
disease,  268,  270. 
on  age  of  first  menstruation,  82. 
on  duration  of  menstrual  period,  84. 
Pericarditis  due  to  syphilis,  383. 
Perineum,  abscess  of,  276. 
complete  tear  of,  33,  479. 
method   of    immediate   repair    of,   484, 

485. 
protection  of,  in  labor,  483. 
Periosteum,  syphilis  of,  427,  442. 
Periostitis,  syphilitic,  427,  428. 
Peritoneum,  gonocoecus  in,  378. 

syphilis  of,  427. 
Peritonitis,  gonorrheal,  in  child,  280. 
Peritonitis,  pelvic,  after  scarlatina,  268. 
after  smallpox,  268. 
cause  of  sterility,  366. 
Periuterine         inflammation,         abortion 
•    caused  by,  473. 
dysmenorrhea  with,   110. 
hyperthyroidism  with,  575. 
Persuasion    in    treatment    of    functional 

neuroses,   583. 
Pessaries,  atresia  of  genital  tract  caused 
by,  145. 
choice  of,  329. 


INDEX. 


679 


Pessaries,  cleanliness  essential  in  use  of, 
282,  325. 
douches  with,  331. 
essentials  for  use  of,  326. 
in  dysmenorrhea,  117. 
in  palliative  gynecology,  31. 
in  prolapse  of  uterus,  333. 
indications  for  use  of,  324. 
infection  conveyed  by,  282. 
measurement  for,  326. 
method  of  introduction  of,  328,  329. 
pruritus  caused  by,  296,  299. 
use  of,  in  fibroid  tumors,  506. 

in  retrodisplacements,  324,  326. 
vaginitis  caused  by,  282. 
varieties  of,  325. 
galvanic-stem,  155. 
Gehrung,  325,  327. 
Hodge,  325,  329. 
lever,  329. 
Menge,  329,  330. 
ring,  325,  327,  329. 
in  position,  330. 
Smith,  325,  329. 

Smith-Thomas-Munde,  325,  329. 
Zwank,  330. 
Peters,  on  adrenalin  in  treatment  of  in- 
operable cancer,  542. 
Peterson,    E.,    on    fatty    degeneration    of 
heart  in  fibroid  tumors,  496. 
on  relation  of  appendicitis  to  pelvic  af- 
fections, 586,  587. 
Pfliiger's  theory  of  menstruation,  78. 
Phalanges,   syphilis   of,  428. 
Pharynx,  chancre  of,  403. 
Phlebitis,    danger    of,    in    anemia    from 
fibroid  tumors,  504. 
in  septic  abortion,  471. 
post-operative,   630. 
Phosphorus  poisoning,  abortion  from,  450. 
Phrenasthenia,  569. 

Physical  development  retarded  by  heredi- 
tary syphilis,  435. 
Physical  training   in  education  of  girls, 

59. 
Physician,  duty  of,  in  extra-uterine  preg- 
nancy, 203. 
in  finictional  neuroses,  582. 
in  inoperable  cancer,  533,  542,  633. 
in  mental  distress,  242,  582. 


Physician,  duty  of,  in  post-operative  con- 
valescence, 622,  624,  628. 
in  prophylaxis  of  cancer,  109,  520,  530. 
in  sterility  due  to  husband,  353,  369. 
to  syphilitic  patient  after  marriage, 

448. 
to  syphilitic  patient  before  marriage, 
444. 
liability  of,  to  digital  chancre,  402. 
relations   of,   to   professional  nurse,   in 

nervous  cases,  584. 
responsibility  of,  as  to  conservatism  in 
radical   operation   for  pelvic   in- 
flammation, 344. 
as  to  infection  of  the  pelvic  organs 
during   an  acute   infectious   dis- 
ease, 265,  270. 
Physiognomy  in  hereditary  syphilis,  435. 
Physiological  amenorrhea,  145,  151. 
Piano,  excessive  practice  upon,  injurious 

to  school-girl,  69. 
Pierre-Budin,  on  infants'  food,  43. 

on  instruction  of  mothers,  43. 
Piezometer,  9. 

Pinard,  on  male  sterility,  372. 
Pincus,  on  atresia  of  genital  tract  due  to 
infectious  disease,  143,  265,  266, 
267. 
on  dangers  of  steaming  the  interior  of 
the  uterus,  509. 
Piorkowski,   on  etiology  of  syphilis,  392. 
Pithiatic  phenomena,  567. 
Pityriasis,  rosea,   diagnosis  between,   and 
syphilitic  eruption,  412. 
syphilitic,  414. 

versicolor,  diagnosis  between,  and  syph- 
ilitic eruption,  412. 
Placenta,  gonococcus  infection  of,  378. 

method  of  removing,  483. 
Plaster,   diachylon,   for   syphilitic  psoria- 
sis,  442. 
mercuric,   in   treatment   of   syphilis   of 
bones,  442. 
Playfair,  on  benefits  of  physical  exercises 
to  study,  61. 
on  sex  in  education,  52. 
Playgrounds,  public,  beneficial  effects  of, 

on  health  of  growing  girl,  49. 
Plethora     a     symptom     of     obesity,     244, 
245. 


680 


INDEX. 


Pneumonia,  abortion  during,  455. 
atresia  of  genital  tract  due  to,  267. 
inflammation  of  uterus  due  to,  269. 
Pollack,  Flora,   on  statistics  of  venereal 

disease  in  little  girls,  383. 
PoUakiuria,  543,  554. 
Polyi3,  fibroid,  492. 
mucous,  166,  492. 
nasal,  headache  caused  by,  226. 
placental,  166. 

uterine,  cause  of  sterility,  358,  362,  372, 
373. 
cause  of  uterine  hemorrhage,  166. 
diagnosis    between,    and    threatened 
abortion,  458. 
Polypoid  endometritis,  175,  292,  294. 
Pomeroy    and    Voorhees,    rubber    dilator 

bags  of,  482. 
Population,    reasons   for   present   general 
decline  in,  347. 
right  proportion  of  increase  in,  347. 
Porter,    on    torsion    of    ovarian    cyst    in 
child  mistaken  for  acute  appen- 
dicitis, 591. 
Post-nasal  growths  a  cause  of  defective 

physical  development,  57. 
Post-operative    convalescence,    daily    life 
in,  623. 
diet  in,  625. 
exercise  in,  625. 
fever  in,  634. 
headache  in,  627. 
local  pain  in,  626. 
menstrual  irregularities  in,  627. 
phlebitis  in,  630. 
tonics  in,  624. 
Posture,  dorsal,  in  cervicitis,  288. 

in   examination    of    movable   kidney, 

609. 
in  gynecological  examination,  6. 
in   introduction   of   uterine   tampons 

in  abortion,  465. 
in  treatment  of  gonorrhea,  387. 
of  vaginitis,  284. 
knee-breast,   in  gynecological  examina- 
tion, 23. 
in     gynecological      examination      in 

child,  25. 
in  introduction  of  pack,  324,  509. 
in  rectal  examination,  35. 


Posture,  knee-breast,  in  treatment  of  gon- 
orrhea in  child,  389. 
in  treatment  of  pruritus,  303. 
in  treatment  of  vaginitis,  282,  284. 
in  vaginal  drainage  of  bladder,  538, 
562. 
lateral.     See  Sims', 
lithotomy,  in  dilatation  and  curettage, 

122. 
Sims',    in    gynecological    examination, 
23. 
in  introduction  of  pack,  323,  509. 
in  treatment  of  vaginitis,  285. 
Sims'  exaggerated,  in  gynecological  ex- 
amination, 25. 
standing,  in  gynecological  examination, 
26. 
in  movable  kidney,  609. 
in  prolapse  of  uterus,  321. 
Potassium    bromide,    in    headache    with 
high  arterial  tension,  233,  234. 
in  insomnia,  243. 
prevention   of   abortion,  462. 
Potassium  chlorate  in  treatment  of  pruri- 
tus, 298. 
Potassium    iodide    in    habitual    abortion, 
461,  462. 
in  infantile  syphilis,  443. 
in  syphilic  headache,  323. 
in  tertiary  syphilis,  437,  440. 
Potassium  permanganate,  in  chancre,  404. 
in  gonorrhea,  388,  389. 
in  pruritus,  298. 
in  pruritis  of  pregnancy,  303. 
in  vaginitis,  285. 
Poverty,  cause  of  malnutrition  and  of  in- 
fection, 41. 
Pott's  disease  simulated  by  gummata  of 

the  vertebrae,  425. 
Poultice,   carbolic   acid,   in   treatment   of 

pruritus,  301. 
Pratt,    on    chlorosis,    atrophy    of    gastric 
glands  in,  158. 
hypodermic  use  of  iron  in,  156. 
intestinal  antisepsis  in,  157. 
rest  in,  158. 
Precocious  menstruation,  82. 
Pregnancy,  avoidance  of,  in  syphilis,  448. 
coccygodynia  associated  with,  261,  262. 
diagnosis  in  early  stages  of,  151,  458. 


INDEX. 


681 


Pregnancy,  extra-uterine,  accidents  liable 
to  occur  in,  196. 
anemia  in,  200. 

attachment   of  ovum  to  different  lo- 
calities in,  194. 
diagnosis  of,  199. 
diagnosis  between,   and  appendicitis, 

206,  588,-591. 
etiology  of,  195. 
false  labor  pains  in,  198. 
hemorrhage  in,  206. 
history  of,   194. 

menstrual  irregularities  in,  177,  199. 
normal  pregnancy  and,  201. 
signs  of,  199. 
treatment  of,  206. 
extra-uterine   pregnancy   mistaken  for, 

201. 
fibroid  tumor,  associated  with,  499,  512. 
mistaken  for,  204. 
obstacle  to,  363,  504. 
Hegar's  sign  in,  151,  500. 
intermenstrual  pain  absent  during,  133, 

138. 
malarial  influence  in,  271. 
manual    reduction    of    uterus    in,    322, 

462. 
"molar,"  454. 

movable  kidney  caused  by,  608. 
parotid  gland  enlarged  during,  273. 
prolapse  of  uterus  an  interference  with, 

322. 
pruritus  caused  by,  296,  303. 
ruptured  tubal,  diagnosis  between,  and 

appendicitis,  206,  543. 
sacro-iliac  joints  relaxed  during,  252. 
splanchnoptosis  caused  by,  599. 
vaginismus  a  bar  to,  306. 
vaginitis  in,  281. 
Preparation  of  patient  for  gynecological 

examination,  6. 
Preventive  medicine,  education  of  public 
in  principles  of,  50. 
importance   of  protection  from   syphil- 
itic infection  as  branch  of,  444. 
Priestley,  Sir  W.,  on  intermenstrual  pain, 

132,  138. 
Primiparse,  frequency  of  abortion  in,  453. 
Proctitis,    coccygodynia    associated    with, 
262. 


Proctitis,  diagnosis  between,  and  chronic 
disease  of  uterine  adnexa,  34. 

gonorrheal,  386. 
Proctoscopef  35,  215,  222. 
Prostate  gland,  syphilis  of,  426. 
Prostitutes,  acute  gonorrhea  in,  380,  381. 

frequency  of  gonorrhea  in,  376. 

rectal  gonorrhea  in,  386. 

sterility  of,   384. 
Protargol  in  treatment  of  gonorrhea,  388, 

389. 
Protoiodide  pills  in  syphilis,  438. 
Prouty,  I.  J.,  on  heredity  as  a  cause  of 

headache,  227. 
Prowe,  on  frequency  of  gonorrhea  in  pros- 
titutes, 376. 
Pruritus,  259. 

anal,  33,  262. 

association  of,  with  jaundice,  295. 

definition  of,  295. 

diabetes  the  cause  of,  295,  297. 

diagnosis  of,  297. 

etiology  of,  295. 

electricity  for,  302. 

formulae  for,  298,  300,  301,  302,  303. 

gonorrheal,  298. 

in  child,  298. 

in  men,  296. 

in  old  age,  636. 

in  pregnancy,  303. 

itching  in,  295,  297. 

pessaries   a   cause   of,   299. 

post-menstrual,  299. 

skin  changes  in,  295,  297. 

surgery  in,   302. 

symptoms   of,   297. 

thrush  with,   298. 

treatment   of,   297. 

vaginal  discharge  with,  298. 
Prussia,  Southern,  age  of  first  menstrua- 
tion in,  83. 
Psychasthenia,  569. 

characteristics  of,  569,  573. 

definition  of,  569. 

differentiation  of,  from  other  neuroses, 
569. 

feeling  of  incompleteness  in,  569,   570, 
573. 

frequency  of,  569. 

mental  manias  in,  570,  571. 


682 


IXDES. 


Psychasthenia,  objective  symj)toms  of,  571. 
obsessions  in,   570. 
prognosis    of,    576. 
subjective  syirptoms  of,  569. 
treatment  of,  577. 
Psychic   disturbances,   cause  of   abortion, 
455. 
cause  of  sterility,  367. 
Psycho-analysis,  583. 
Psycho-therapy,  242,  582. 
Psoriasis,  diagnosis  between,  and  miliary- 
papular  syphilide,  414. 
diagTiosis   between,    and   papulo-squani- 

ous  syphilide.  414. 

of     palms,      diagTiosis     between,      and 

palmar     and    plantar    syphilide, 

415. 

syphilitic,  of  tongue.     See  Leucoplasia. 

Ptomaine    poisoning,    headache    due    to, 

225. 
Puberty,  clothing  at,  TO. 
early,  in  chlorosis,  147. 
employment  at,  69. 
exercise  at,  68. 

heredity  in  determining  age  of,  83,  145. 
hygiene  of,  67. 

menstruation  irregular  at,  86. 
physiology  of  reproduction,  instruction 

in,  at,  72. 
sleep  at,  importance  of,  68. 
school-life  in  relation  to,  65. 
Puech,  on  atresia  of  genital  tract  caused 

by  infectious  diseases,  266. 
Puerperal    infection,     appendicitis,     and, 
587. 
pelvic  inflammation  from,  339. 
sterility  from,  357. 
Puerperium,  malarial  influence  upon,  271. 
Purgative  enemata,  222. 
Piisey,  W.  A.,  on  injurious  effects  of  tryp- 
sin in  inoperable  cancer,  539. 
Pyelitis,  albmninuria  in,  548,  549. 
artificial  abortion  indicated  in,  474. 
diagTiosis  between,  and  cystitis,  549. 
pyuria  in,  548. 
Pylorus,  tumor  of,  mistaken  for  movable 

kidney,  615. 
Pyopietra  in  cervical  cancer,  533,  534. 
in  old  age,  639. 
in  senile  endometritis,  294. 


Pyo-physometra    in    senile    endometritis, 

294. 
Pyosalpinx,  labor  followed  by,  479. 

sterility  associated  with,  365,  374. 
Pyuria,   acid,  association  of,  with  tuber- 
culosis, 550,  557. 
in  cystitis,  548,  549. 
in  pyelitis,  548. 

thickening  of  ureter  associated  with,  in 
tubercular  kidney,  13. 

Quack  literature  on  coccygodynia,  263. 
Quacks,  coal-tar  preparations  misused  by, 
235. 
treatment  of  fibroid  tumors  by,  505. 
treatment  of  headache  by,  224. 
treatment  of  male  sterility  by,  352. 
Quinine,   contractions   of  uterus  induced 
by,  469. 

Radium  iu  treatment  of  uterine  cancer, 

537. 
Payer,  on  relation  of  hysteria  to  floating 
kidney.  597. 
on  swelling  of  leg  associated  with  mov- 
able kidney,  613. 
Reception  room,  physician's,  1. 
Rectal  enemata.     See  Enemata. 
Rectal  valves,   thickening  of,   a  cause  of 

constipation,  213. 
Recto-abdominal  examination,  12,  13. 
in  child,  26. 
in  virgins,  27. 
Rectocele,  19,  479. 

Rectum,   cancer  of,   a  cause  of  constipa- 
tion, 215. 
mistaken  for  a  pelvic  tumor,  34. 
dysmenorrhea    due    to    overloading    of, 

33. 
examination     by,     in     appendicitis     in 
child,   596. 
in  constipation,   215. 
in  gynecological  practice,  33. 
in  imperforate  hymen,  151. 
instruments  required  for,  35. 
method  of  conducting.  35. 
of  pelvic  organs,  in  child,  26. 
in  virgins,  27. 
extension   of   cancer  of  cervix  to,   513, 
524. 


INDEX. 


683 


Rectum,  fibroid  tumor  pressing  upon,  33, 
498,   503. 
fissure  of,   34,   38. 

gonococcus  infection  of,  3Y6,  378,  386. 
inflammation  of.     See  Proctitis, 
inspection  of,  through  head-mirror,  36. 
pelvic   disease   extending   to,   33. 
separation  of,  from  attachments  of  le- 
vator   ani    muscles    after    labor, 
479. 
stasis  of  pelvic  blood-vessels  from  over- 
loading of,  33. 
stricture  of,  38. 
syphilis  of,  423. 

temperature  in,  in  appendicitis,  associ- 
ated with  dysmenorrhea,  593,  594. 
treatment  of  disease  in,  38. 
Re-education,  in  treatment  of  functional 

neuroses,  584. 
Reichert's  theory  of  menstruation,  78. 
Relapsing  fever,   inflammation   of  uterus 

from,  269. 
Relatives,  marriage  between,   a  cause  of 

sterility,  368. 
Renal   colic,   artificial  production   of,   29, 
617. 
in  movable  kidney,  610. 
treatment  of  an  attack  of,  619. 
Reproduction,   instruction   of  young  girl 

in  physiology  of,  72. 
Repulsion  a  cause  of  sterility,  367. 
Respiratory  system,  syphilis  of,  424. 
Rest,    therapeutic    uses    of,    during   men- 
strual period,  73,  627. 
during   post-operative   convalescence, 

623. 
in   chancre,   404. 
in  chlorosis,   158. 
in    dysmenorrhea,    113. 
in  functional  neuroses,  576,  577. 
in  gynecological  affections  in  general, 

30. 
in  hemorrhage  from  uterus,  183,  184, 

506,  509. 
in  imminent  abortion,  462,  463. 
in    insomnia,    242. 
in  intermenstrual  pain,  137. 
in  splanchnoptosis,  603. 
Rest  cure,  576,  577. 
Retina,  syphilis  of,  429. 


Rheumatic  diathesis,  in  amenorrhea,  149. 
in  dysmenorrhea,  96. 
in  headache,  225,   234. 
in  migraine,  235,  236. 
in  obesity,  244,  248. 
Rheumatism,  acute,  a  cause  of  ovarian  in- 
flammation,  270. 
a  cause  of  sterility,  366. 
muscular,  relation  between,  and  coccy- 

godynia,  261. 
sacro-lumbar,    diagnosis    between    and 
sacro-iliac  joint  affections,  251. 
treatment   of,   256. 
Rhubarb  in  constipation,  220. 
Richards,    Mrs.    Ellen    H.,    on    training 
young    girls    for    the    duties    of 
home,  42. 
Richter,  case  of  atresia   of  genital  tract 

due  to  smallpox,  266. 
Ricord,  on  chancre  as  source  of  infection 

in  syphilis,  449. 
Riedl,    case    of   precocious   menstruation, 

82. 
Riegel's  theory  of  menstruation,  79. 
Riis,  method  of  radical  operation  in  can- 
cer, 530. 
Rilli  and  Vockenrodt,  on  attachment  of 
the  spirocheta  pallida  to  the  red 
blood  corpuscles,  432. 
Riva-Rocci  instrument  for  measuring  ar- 
terial tension,  226. 
Rokitansky,    on    attachment    of   ovum   to 
cervical  mucous  membrane,  458. 
on  chlorosis,  147. 
Rollet,   on  hysteria   and  movable  kidney, 

597. 
Rose's  method  of  bandaging  in  splanch- 
noptosis,  555. 
Roseola,  syphilitic,  412. 
Rosinski,    on   presence    of   gonoccocus   in 

mucous  membranes,  378. 
Rubber  bags,  dilatation  of  cervix  in  labor 

with,  482. 
Ruge,  C,  on  formation  of  papillae  in  vagi- 
nitis,  280. 
on  treatment  of  pruritus,  301. 
Rupia,  418. 

Sacro-iliac  joints,  relaxation  of,  backache 
in,  252. 


6Si 


IISDEX. 


Sacro-iliac   joints,   relaxation   of,   charac- 
teristics of,  252. 
etiology  of,  252. 
objective  symptoms  of,  255. 
referred  pains  in,  255. 
subjective    symptoms,    254:. 
treatment    of,   259. 
Salicylate   of   soda    in   diabetic   pruritus, 

302. 
Salicylic   acid,   in  treatment   of   condylo- 
mata, 442. 
Saline  infusion,  in  bemorrbage  from  ex- 
tra-uterine pregnancy,  206.   . 
in  menorrbagia,  184. 
preparation  of,  184. 
Saline  laxatives,  in  cblorosis,  157. 
in  constipation, .  221. 
in  beadacbe,  231. 
Salivation    in     mercurial    treatment     of 

syphilis.   43S. 
Salol  iu  treatment  of  chlorosis.  157. 
Salpingitis,  association  of,  \rith  dysmen- 
orrhea, 110,  111. 
with  sterility,  358. 
diagnosis    between,     and     appendicitis, 

587,  588,  590. 
diagnosis    between,     and    extra-uterine 

pregnancy,   173.   591. 
syphilitic.  427. 
Salvarsan  in  syphilis.  408. 
Sampson,   J.   A.,  on  drainage  of  bladder 
after    hysterectomy    for    cancer, 
577. 
on    method    of    radical    operation    for 
cancer,  530. 
Sanger,      on     infection     of     Bartholin's 
glands,  359. 
on  gonococcus  as  cause  of  sterility,  351. 
on  male  sterility,  353,  354. 
on  pruritus  in  diabetes,  295. 
on  relation  between  female  sterility  and 

absence  of  sexual  feeling.  267. 
on   treatment    of   constipation   without 

drugs.  219.  223.  625. 
on  treatment  of  infections  of  the  vag- 
ina with  chloride  of  zinc  in  solu- 
tion, 374. 
Sanger  and  Schwartz  on  the  percentage 
of  gonorrhea  among  all  patients, 
376. 


Sanger's     "maculae     gonorrhoicae,"     359, 

385. 
Sanitary  inspection  of  schools,  58. 
Sanitation,  public,  influence  of,  on  indi- 
vidual health,   44. 
Sarcoma  of  kidney  in  child,  26. 

of  uterus,  a  cause  of  hemorrhage,  170. 
Sarcomatous   degeneration  of  fibroid  tu- 
mors, 496. 
Scanzoni,  case  of  atresia  of  genital  tract 
due  to  smallpox,  266. 
on  caustic  potash  for  pruritus,  301. 
on  fibroid  ttunors  in  causation  of  ster- 
ility,  504. 
on  pregnancy  and  labor  as  the  cause  of 
coccygodyuia,  261. 
Scar,  abdominal,  enlargement  of,  632. 

tenderness  in,  632. 
Scarification  of  cervix  uteri   in   amenor- 
rhea  accompanied  by  menstrual 
molimina,   159. 
Scarlatina,  abortion  in,  455. 

atresia  of  genital  tract  from,  267. 
atresia  of  vagina  from,  143,  266. 
inflammation  of  ovaries  in,  268. 
pelvic  peritonitis  after,  268. 
Scarlet-fever.     See  Scarlatina. 
Schaudinn   and   Hoffmann,    discovery   of 

spirocheta  pallida,  392. 
Scheuk,  F..  on  statistics  of  male  sterility, 

353. 
Schenk's   Sea-weed   Tonic,   percentage  of 

alcohol  in,  114. 
Schiller,  H.,  on  yeast  treatment  of  vagini- 
tis,  286. 
Schleich's    solution    of    cocain    and   mor- 
phin,  formula  for.  277. 
in  abscess  of  Bartholin's  gland,  277. 
in  treatment  of  pruritus,  302. 
Sclerosis,    early    multiple,    diagnosis    be- 
tween,   and   functional  neuroses, 
579. 
Schmalfuss,    on   reflex   symptoms    accom- 
panying an  artificial  menopause, 
629. 
School    buildings,    necessity    for    medical 

inspection  of,  58. 
School-girl,  age  of.  on  entrance,  51. 
amenorrhea  in.  from  overstudy.  155. 
assymmetrv  in,  63. 


INDEX. 


685 


Scliool-girl,  athletics  for,  61. 
bowels,  care  of,  in,  53. 
breakfast  a  necessity  to,   53. 
desk,  proper  height  of,  for,  60. 
dress  of,  53. 

dysmenorrhea  in,  66,  109,  113. 
gymnastics  for,  59. 
hygienic  habits  in,  52. 
importance  of  attention  to  physical  de- 
fects in,  57. 
medical  inspection  of,  43,  50,  54,  62. 

at  intervals,  63. 
menstrual  function  in,  72. 
out-door  exercise  for,  61. 
physical  training  of,  59. 
spinal   curvature  in,   62.- 
teeth,  care  of,   in,   53. 
School-teachers,  necessity  for  instruction 

of,  in  hygiene,  59. 
School  for  girls,  architecture  of,  58. 
beneficial  effects  of,   66. 
centres  of  infection,   58. 
defective  hygiene  in,  58. 
gymnastics   in,   60. 
medical  inspection  in,  43,  50,  54. 
playgrounds  attached  to,  61. 
provision  of  lunch  in,  56. 
seating  in,  60. 

toilet  accommodations  in,  59. 
Schreiber,    on    method    of    massage    for 
sacro-lumbar  rheumatism,  257. 
on  motion  in  treatment  of  sacro-lumbar 

rheumatism,  257,  258. 
on  muscular  rheumatism  of  sacral  re- 
gion, 252. 
Scoliosis,    prevention    of,    by    corrective 
gymnastics,  62. 
theory    of    association    of,   with    faulty 
construction  of  the  bodies  of  the 
vertebrae,   62. 
treatment  of,  63. 
Scriptures,  verses  from,  on  sterility,  347, 
350. 
on  gonococcus  infection,  375. 
Schroder,  on  fibroid  tumors  in  causation 

of  sterility,  504. 
Schulthess,  on  relation  of  schools  to  lat- 
eral spinal  curvature,  62. 
Sciatica  mistaken  for  a  neurosis,  565. 
Seborrhea  of  scalp  in  syphilis,  420. 


Seborrhea  of  scalp  in  syphilis,  diagnosis 
between,    the    circinate    papular 
syphilide,  415. 
Secretions,  from  cervical  glands,  275,  287. 
gonorrheal,  298,  385,  389. 
in  cervicitis,  287. 
in  endometritis,  senile,  294. 
in  pelvic  inflammation,  339. 
in  pruritus,  299. 
in  syphilis,  all  contagious,  398. 
in  vaginitis,  280,  282,  283. 
in  vulvitis,  276. 

in  young  children,  381. 
irritating,  a  cause  of  pruritus,  295,  296. 
method  of  collection  of,  for  microscopi- 
cal examination,  276. 
normal  vaginal,  fatal  to  gonococcus,  379. 
Sedative   enemata   in   treatment    of    dys- 
menorrhea, 115. 
in  treatment  of  pruritus,  299. 
Sedatives  in  cystitis,  558. 
in    dysmenorrhea,    114. 
in  headache,  234. 
in  inoperable  cancer,   541. 
in  insomnia,  242. 
in  masturbation,  316. 
in  threatened  abortion,  462. 
in  vaginismus,  307. 
in  vomiting  of  chlorosis,  local,  158. 
Seeligman,     on    treatment    of    vicarious 

menstruation,  162. 
Seeligmuller,   on  relation  between  coccy- 
godynia  and  neuralgia,  262. 
on  treatment  of  coccygodynia,  263. 
Seitz,  L.,  on  hydramnion  in  early  preg- 
nancy, 454. 
on    syphilis    in   causation   of    abortion, 
455. 
Sellheim,  H.,  on  incomplete  abortion,  458. 
Semen,  method  of  collecting,  for  exami- 
nation, 353. 
Semola,  on  syphilitic  influence  in  angina 

pectoris,  425. 
Sepsis,    dangers    of,    from    remnants    of 
abortion,  190. 
in  catheterization,  556,  557. 
in  curettage,  189,  373. 
in  expectant  treatment  of  threatened 

abortion,  463. 
in  intra-uterine  treatments,  509. 


686 


INDEX. 


Sepsis,  dangers  of,  in  mechanical  evacu- 
ation of  uterus,  467. 
in  operation  for  imperforate  hymen, 

154. 
in  tents  for  dilatation  of  cervix  uteri, 

122. 
in  uterine  tampons,  465, 
precautions    against,    by    obstetrician, 
482,  486. 
Serum,  antigonococcus,  379. 
Serum-therapy  in  syphilis,  440. 
Severinus  Pinseus,  on  rupture  of  hymen, 

359. 
Sewage,  necessity  for   adequate  removal 

of,  44. 
Sewing-machines,  excessive  use  of,  at  pu- 
berty injurious,  69. 
Sexual  activity  associated  with  precocious 

menstruation,  82. 
Sexual  emotions,  disturbances  of,  associ- 
ated with  sterility,  367. 
in  neurasthenia,  568. 
Sexual  intercourse,  excessive,  a  cause  of 
abortion,  455. 
prohibition  of,  in  threatened  abortion, 
462. 
in  treatment  of  vaginismus,  306. 
"  Sexual  spots,"  109. 

Shape  of  body   associated  with  movable 
kidney,  607,  609. 
with  splanchnoptosis,  600,  601,  602. 
Shock,  in  the  etiology  of  amenorrhea,  149, 
367. 
of  functional  neuroses,  568. 
Shoemaker,    G.    E.,    on    hemorrhage    in 
early    diagnosis   of   uterine   can- 
cer, 520. 
Shoes  for  young  girl,  71. 
Sick  headache.     See  Migraine. 
Sierra  Leone,   age  of  first  menstruation 

in,  83. 
Sigmoid  flexure,  condition  of,  in  constipa- 
tion, 215. 
palpation  of,  9. 

redundancy  of,  a  cause  of  constipation, 
213. 
operation  for  relief  of,  213. 
Sigmoidoscope,  35. 

Silver,  nitrate  of,  formula  for  solution  of, 
561. 


Silver,    nitrate    of,    in    causation    of    ex- 
foliative vaginitis,  281. 
in  treatment  of  cervical  cancer,  536. 
of   chancre,  404. 
of  cystitis,  334,  560. 
of  endocervicitis,  288. 
of  gonococcus  infections,  307,  387, 

388,  389,  391. 
of  mucous  patches,  442. 
of  pruritus,  300,  301. 
of  pruritus  in  pregnancy,  303. 
of    rectal    disease,    38. 
of  senile  endometritis,  294. 
of  vaginitis,  284. 
Simon,  C.  E.,  on  reduction  of  hemoglobin 

in  chlorosis,  153. 
Simpson,  J.,  on  pruritus  of  diabetic  ori- 
gin  (formula),  302. 
Simpson,    J.    Y.,    on    atresia    of    cervix 
caused  by  application  of  the  ac- 
tual cautery,  145. 
on  coccygodynia,  260,  261,  262,  263. 
on  membranous  dysmenorrhea,  128. 
on  the  mechanical  theory  of  dysmenor- 
rhea, 107. 
Sims,  J.  Marion,  on  examination  of  rec- 
tum, 34. 
on  mechanical  theory  of  dysmenorrhea, 

107. 
on    surgical    treatment    of    vaginismus, 

308. 
on  vaginismus,  304,  306,  368. 
Sims'  posture.     See  Posture. 
Sims'  speculum.     See  Speculum. 
Skene,  on  age  of  first  menstruation,  87. 
on   local   changes    in    genitalia    accom- 
panying the  menopause,  88. 
on  typhoid  fever  followed  by  atresia  of 
the  genital  tract,  266. 
Skene's    glands,    infection    of,    in    gonor- 
rhea, 380,  381,  385. 
in   vulvitis,    276. 
method    of    exposing,    388. 
sterility  due  to  gonorrheal  infection  of, 

358,  359,  374. 
treatment   of   gonorrheal   inflammation 

of,  388. 
treatment   of  inflammation   of,  278. 
Skin,  affections  of,  in  young  girls,  owing 
to  malnutrition,  55,  58. 


INDEX. 


687 


Skin,  changes  of,  in  pruritus,  295,  297. 
eruptions  of,  associated  with  menstrua- 
tion, 106. 
hereditary  syphilis  of,  435. 
syphilis  of  appendages  of,  420. 
Skrobansky,  on  inflammation  of  the  ova- 
ries in  acute  infectious  diseases, 
268,  269,  270. 
Smallpox,  atresia  of  genital  tract  follow- 
ing, 266. 
in  fetus,  454. 

pelvic  peritonitis  after,  268. 
Smegma    bacillus,    mistaken    for    pus    in 

urine,  549. 
Smith,  A.  L.,  on  electrical  treatment  of 

dysmenorrhea,  117. 
Smoke,  dangers  of,  to  public  health,  44. 
Smoking.     See  Tobacco. 
Social    life,    influence    of,    on    health    of 

women,  75. 
Sodium      bicarbonate      in      disinfecting 

douche,  331. 
Sodium,  bromide  in  treatment  of  dysmen- 
orrhea (rectal  enema),  115. 
of  headache  with  high   arterial  ten- 
sion, 233,  234. 
of  insomnia,  243. 
of  pruritus  (rectal  enema),  299. 
Sodium  nitrite  in  headache  with  high  ar- 
terial tension,  233. 
Sodium  phosphate  in  treatment  of  consti- 
pation, 218. 
Sodium  salicylate  in  rheumatic  headache, 

234. 
Soupault  and  Jouaust,  on  dysmenorrhea 

caused  by  appendicitis,  592. 
Spa  treatment  of  obesity,  246. 
Specula,  rectal,  35,  36,  38. 

tubular,   in   vaginismus,   308. 
Speculum,  Burrage's  uterine,  509. 

Kelly's   cylindrical   metal,   for   examin- 
ing pelvic  organs  in  knee-breast 
posture,  23. 
for  examining  the   pelvic   organs   in 

the  Sims'  postvire,  24. 
for  insertion  of  vaginal  tampon,  187. 
for  painting  the  cervix,  31. 
for  treating  gonorrhea  in  a  child,  389. 
Nelson's.      See   Trivalve. 
Sims',  in  dilatation  of  the  sphincter,  39. 


Speculum,  Sims',  in  examination  of  pel- 
vic organs  in  Sims'  posture,  23. 
in  examination  of  rectum,  34. 
in  insertion  of  intra-uterine  tampons, 

465. 
in  introduction  of  vaginal  tampons, 

187. 
in  treatment  of  gonorrhea,  387. 
trivalve,   in   insertion   of   vaginal  tam- 
pons, 187. 
in  inspection  of  vagina,  19. 
tubular,  in  acetone  treatment  of  cancer, 
540. 
in  treatment  of  vaginismus,  308. 
vesical,  in  examination  of  bladder,  532. 
in  examination  of  vagina  in  child,  25. 
Sphincter  area,  dilatation  of,  38. 
Sphincter  vaginae,  division  of,  in  vaginis- 
mus, 308. 
Sphincteroscope,  fenestrated,  38. 
Spina  ventosa,  428. 
Spinal-cord,  syphilis  of,  431. 
Spine,    lateral    curvature    of,    in    school- 
girls, 62. 
improvement  of,  under  systematic  gym- 
nastic exercises,  64. 
Spirocheta  pallida,   demonstration   of,   in 
lesions  and  in  fetus,  392,  393. 
disappearance  of,  on  administration  of 

mercury,  393. 
discovery    of,    392. 
in  blood-vessels,  397. 
in   chancre,   402. 
in  heredo-syphilitic  lesions,  434. 
in  mixed  chancre,  400. 
in  renal  epithelium,  398. 
in  syphilitic  lesions  in  apes,  393. 
value  of,  in  diagnosis  of  syphilis,  402, 
445. 
Splanchnoptosis,  anatomical  basis  of,  597. 
characteristic  body  shape  of,  600,   601, 

602. 
definition    of,    597. 
diagnosis    of,    601. 
etiology   of,   599. 
frequency   of,   602. 

hygienic  measures  of  treatment  of,  603. 
medical  treatment  of,  603. 
operative  treatment  of,  604. 
relation  of,  to  neurasthenia,  599. 


688 


IISTDEX. 


Splanchnoptosis,  symptoms  of,  599. 
treatment  of,  by  bandaging,  603. 
Spleen,  displacement  of,  601. 

syiJhilis   of,   424. 
Spondylitis,  syphilitic,  428. 
Sponge  tents.     See  Tents. 
Sprague,   W.   B.,   on  electricity  in  treat- 
ment of  dysmenorrhea,  with  de- 
scription of  method,  117. 
Standing  posture,   examination   in.     See 

Posture. 
Stanley,  on  chlorosis,  156. 
Starch,  reduction  of,  in  food,  in  treatment 

of  obesity,  246. 
Steam,  cauterization  of  uterine  cavity  by, 

136,    509. 
Stengel,  on  chlorosis,  146,  157,  158. 
Stephenson,  W.,  on  chlorosis,  146,  155. 
Sterdele,  case  of  atresia  of  genital  tract 

caused  by  typhoid  fever,  266. 
Sterility,  346. 
absolute,  346. 
acquired,  347. 
congenital,   347. 
definition    of,    346. 
development  of  knowledge  concerning, 

351. 
duty  of  physician  in,  353,  369. 
etiology  of,  in  female.     See  below. 

in  males.     See  below, 
intermenstrual    pain    associated    with, 

133. 
laws  governing,  348,  349,  350. 
morality  of,  347. 
national  importance  of,  347. 
one-child,  346,  362,  366,  384. 
period  after  marriage  when  it  begins, 

349. 
prevalence  of,  347. 
progressive,  347. 
relative,   346. 
relative  at  different  epochs  in  marriage, 

349. 
schemes  for  examination  for,   in,  370, 

371. 
treatment  of.     See  below. 
Sterility  in  female,  caused  by  anaphrodi- 
sia,  367. 
by  anatomical  and  physiological  pe- 
culiarities, 357. 


Sterility  in  female,  caused  by  affections 
of  neck  of  uterus,  361. 
by  atresia  of  vagina,  142,  360. 
by  cervical  affections,  361,  362. 
by  constitutional  conditions,  366. 
by  displacements  of  uterus,  363. 
by  dyspareunia,  367. 
by  endometrial  affections,  362. 
by  fibroid  tumors,  363,  393,  504. 
by    gonococcus    infection,    358,    361, 

365,  384. 
by  imperforate  hymen,  359. 
by  infantile  uterus,  363. 
by   infection    of   Bartholin's    glands, 

359. 
by  infection  of  Skene's  glands,  359, 

374. 
by  ovarian  affections,  365. 
by  relaxation  of  vaginal  outlet,  360. 
by  repulsion,  367. 
by  stenosis  of  cervix,  361. 
by  tubal  affections,  365. 
by  vaginismus,  306,  368. 
treatment  of,  369. 

by  cauterization  of  cervix,  374. 

by  cauterization  of  vagina,  374. 

by  correction  of  displacements,  372. 

by  curettage,  373. 

by  dilatation  of  cervix,  372. 

by  enucleation  of  fibroids,  373. 

by  excision  of  hymen,  372. 

by     incision      of     Bartholin's      and 

Skene's  glands,  374. 
by     opening     and    draining     uterine 

tubes,  374. 
by  removal  of  parovarian  cysts,  373. 
by  removal  of  uterine  polyps,  373. 
by  treatment  for  gonorrhea,  374. 
Sterility  in  male,  forms  of,  351. 
frequency  of,  353. 
history  of  knowledge  in,  350. 
method  of  examining  for,  353. 
prognosis  in,  353,  369. 
statistics  as  to  frequency  of,  354,  355, 
356. 
Sterilization  of  instruments,  6. 

of  towels,  465. 
Stern  and  Jacquet,  on  the  gonococcus  in 

the  pus  of  inflamed  joints,  378. 
von  Stellwag's  sign,  576. 


INDEX. 


689 


Stiller,    on    etiology    of    splanchnoptosis, 

599. 
Stimulants,  alcoholic  avoidance  of,  in  in- 
somnia, 241. 
in   combination    with    coal-tars,    114, 

235. 
in  treatment  of  dysmenorrhea,  113. 
Stomach,  displacement  of,  597. 
diagnosis  of,  601. 
operative  treatment  of,  604. 
symptoms  of,  600. 
dilatation  of,  and  migraine,  228. 
fermentation   of,   a  cause  of  insomnia, 

241. 
palpation  of,  8. 
syphilis  of,  423. 
Stomatitis,  mercurial,  diagnosis  between, 
and   syphilis   of   the   oro-pharyn- 
geal  cavity,  422. 
Storer,  M.,  on  intermenstrual  pain,  134. 
Strain,  nervous,  in  causation  of  neuras- 
thenia, 568. 
Strassmann,  cases  of  precocious  menstru- 
ation, 82. 
on  fibroid  tumors  and  heart  disease,  505. 
on  relation   of   sterility  to   absence   of 
sexual  feeling,  367. 
Stratz,    on    amylaceous    degeneration    of 

fibroid  tumors,  496. 
Strauss,  Nathan,  interest  of,  in  free  milk 

stations,  44. 
Stricture  of  intestine,  cause  of  constipa- 
tion, 213,  222. 
of  rectum,  examination  of,  38. 
of  urethra,  in  women,  360. 
Stumpif,  on  statistics  of  abortion,  453. 
Sturgis,  r.  E,.,  on  parallel  between  consti- 
tutional   effects    in    syphilis    and 
gonococcus  infection,  377. 
Stypticin  in  treatment  of  uterine  hemor- 
rhage, 185,  508. 
Styptol   in  treatment   of   uterine  hemor- 
rhage, 185. 
Suburethral  abscess,  278. 
Suction  apparatus  for  removal   of  urine 

from  bladder,  552. 
Suggestion,  susceptibility  to,  in  hysteria, 
566. 
in  treatment  of  functional  neuroses, 
583. 
45 


Suggestion,  susceptibility  to,  in  treatment 

of  insomnia,  541. 
Sulphonal  in  treatment  of  functional  neu- 
roses, 581. 
in  treatment  of  insomnia,  242,  243. 
Suppositories,      rectal,     belladonna      and 
opium  in  cystitis,  558. 
glycerin,  in  constipation,  221. 
patent  medicines  in,  281. 
trional  and  codein  in  cystitis,  558. 
vaginal,    in    displacements    of    uterus, 
332. 
in  gonococcus  infection,  389. 
Suprarenal  gland,  changes  in,  associated 
with  sterility  and  obesity,  367. 
extract  of.     See  Adrenalin. 
Suppuration  of  abdominal  wound  in  post- 
operative convalescence,  631. 
Sutton,  Bland,  on  number  of  fibroid  tu- 
mors, 488. 
on  seedling  fibroids,  495. 
van   Swieten,  liquor  of,  in  treatment  of 

syphilis,  438. 
Swimming  pools  for  girls,  61. 
Syphilides,  acne  form  of  pustular,  416. 
circinate  papular,  415. 
confluent  impetiginous,  417. 
diagnosis    of,    412. 
ecthyma  form  of  pustular,  417. 
erythematous,  411. 
gummatous,    418. 
impetigo  form  of  pustular,  417. 
lenticular,   413. 
lichenoid,  414. 
macular,  412. 
maculo-papular,  412. 
miliary  papular,  414. 
moist  papular,  415. 
nummular,  413. 
palmar,    415. 
papular,  413. 
papulo-squamous,  414. 
pigmentary,   412. 
plantar,    415. 
pustular,  416. 
serpiginous,    419. 
tubercular,  418. 
variola  form  of  pustular,  416. 
vegetating,  419. 
vesicular,  416. 


690 


INDEX. 


Syphilis,  abortion  from,  445. 

accidental  causes  influencing,  396. 

benign  rapid,  396. 

causal  agent  in,  392. 

conceptional,  433. 

congenital,  432. 

definition  of,  392. 

eruption  of,  394. 

evolutionary  modes  of,  393. 

fever  in,  394. 

headache  in,  226,  233,  394. 

ignorance  a  cause  of  transmission  of,  in 

marriage,  449. 
infantile,   434,   443. 
infiltration   in,   395. 
initial  lesion  of,  393,  399. 
inoculation  of,  398. 

instruments  a  cause  of  infection  in,  6. 
intermediate  period  of,  394. 
iodide  of  potash  in  treatment  of,  437, 

440. 
irregular,  396. 
marriage  and,  443. 

mercury  in  treatment  of.     See  Mercury, 
morbid  anatomy  of,  397. 
mouth,    hygiene    of,    in    treatment    of, 

441. 
mucous  patches  the  chief  source  of  in- 
fection in,  449. 
parasyphilis,  396. 
post-conceptional,   434. 
precocious  malignant,  396. 
primary  incubation  of,  393,  399. 
primary  stage  of,  393. 
prodromal  symptoms  of,  394. 
prophylaxis  of,  by  education,  449. 
reinfection   in,   397. 
secondary  incubation  of,  394. 
secondary  stage  of,  394. 
sources  of,  398. 
stages  of,  393. 
toxines    in,    396. 
transmission    of,    to    third    generation, 

436. 
treatment  of,  437. 

antinervine   in,   441. 

dermo-pulmonary,  method  of,  439. 

duration   of,   440. 

hygienic  measures  of,  441. 

hypodermic  method  of,  489. 


Syphilis,  treatment  of,  in  late  manifesta- 
tions, 446. 

ingestion   method   of,   438. 

intermittent  method  of,  438. 

inunction  method  of,  438,  443. 

iodide  of  potash  in,  437,  440. 

mixed,  440. 

object  of,  437. 

salvarsan    in,    408. 

time  for  beginning,  437. 

Wassermann  reaction  in,  405. 
variations  of  type  of,  395. 
Syphilis,  hereditary,  432. 

conceptional,  433. 

manifestations  of,  434. 

maternal  transmission  of,  433. 

mixed  transmissions  of,  433. 

modifications  of,  433. 

paternal  transmissions  of,  432. 

post-conceptional,  434. 

teeth  in,  435. 

treatment    of,   443. 
Syphilis,  primary,  abortive  treatment  of, 
404. 

bubo,   402. 

chancre,    399. 

diagnosis    of,    402. 

incubation  period   of,   399. 

initial  lesion  of,  399. 

prognosis    of,    403. 

situation  of  lesions  of,  400,  402. 

treatment  of,  404. 
Syphilis,    secondary,    characteristics    of, 
411. 

diagnosis  of,  412. 

syphilides  in,  411. 

treatment  of,  442. 

varieties  of,  411. 
Syphilis,  tertiary,  diagnosis  of,  419. 

of  alimentary  system,  419. 

of  appendages  to  skin,  420. 

of  circulatory  system,  424. 

of  eye  and  ear,  428. 

of  female  reproductive  organs,  426. 

of  genito-urinary  system,  425. 

of  motor  system,  427. 

of  nervous  system,  430. 

of  oro-pharyngeal  cavity,  421. 

sjTDhilides  of,  418. 

treatment  of,  440. 


INDEX. 


691 


Syphilis  and  marriage,  443. 

duty  of  physician  after,  448. 

duty  of  physician  before,  446. 

safety  in,  443. 

secrecy  in,  447. 

social    effects    of,    444. 

sources  of  infection  in,  449. 

statistics  of,  449. 
Syphilo-toxines,  396. 
Syrup   of  Gibert,  438. 

Tabes,  association  of,  with  syphilis,  431, 
446. 
diagnosis  between,  and  functional  neu- 
roses, 5Y4. 
prevention  of,  by  mercuric  treatment, 
437. 
Tables  on  annual  birth-rate,  348. 

on  duration  of  menstrual  period,  84. 
on  examination  of  physical  condition  of 

school-children,  55,  65. 
on   initial   fecundity   of   women   under 

twenty,  349. 
on  intermenstrual  pain,  134. 
on  interval  between  marriage  and  birth 

of  first  child,  350. 
on  interval  between  menstrual  periods, 

86. 
on  menopause,  89. 

on  relative  sterility   at   different   ages, 
349. 
Tait,  Lawson,  on  pelvic  peritonitis  asso- 
ciated with  acute  infectious  dis- 
ease, 268. 
Tait  and  Wiggin,  case  of  removal  of  ap- 
pendix, 587. 
Tampons,  uterine,  asepsis  in  use  of,  465, 
466. 
in  abortion,  465. 
in  uterine  hemorrhage,  187. 
method  of  introduction  of,  187,  465. 
vaginal,  boroglycerid  in,  285,  324. 
function  of,  31. 
in  abortion,  461,  464. 
in  displacements  of  uterus,  353. 
in  fibroid  tumors,  509. 
in  gonorrhea,  389. 
injudicious  use  of,  324. 
in  menorrhagia,  186. 
in  prolapse  of  uterus,  334. 


Tampons,  vaginal,  in  pruritus,  299. 
in  retrodisplacement,  323. 
•    in  uterine  hemorrhage,  186,  464,  509, 
642. 
in  vaginitis,  285. 
method  of  introducing,  323. 
Tarnowsky,  on  influence  of  syphilis  in  so- 
ciety, 437. 
Taylor,    J.    M.,    on   physical   training    of 

children,  59,  62. 
Taylor,   K.   W.,   on  gonorrheal   origin   of 

uterine  disease,  376. 
Tea  and  cofl^ee,  avoidance  of,  in  insomnia, 

239,  241. 
Teeth,  care  of,  in  school-girls,  53. 

syphilitic,  435. 
Temper,     effect     of     constipation     upon, 
207. 
headache  caused  by,  228. 
Tendon  sheaths,  gonococcus  in  pus  of  in- 

.    flamed,  378. 
Tendons,  syphilis  of,  427. 
Tenement  houses,  defects  of,  injurious  to 

public  health,  45. 
Tents,  in  treatment  of  chancre,  404. 
sponge,  in  artificial  abortion,  475. 
in  mechanical  evacuation  of  uterus, 

469. 
risks   of,   in  dilatation  of  cervix  for 
dysmenorrhea,  122. 
Testicles,    diagnosis    between    cancer    of, 
and  syphilis  of,  426. 
syphilis  of,  425. 
Theilhaber,  on  atrophy  of  genital  organs 

in  Basedow's  disease,  148. 
Thermal-electric    light    in    treatment    of 
backache,  258. 
in  treatment  of  headache,  233. 
Thomas,  T.  G.,  on  frequency  of  fibroids  in 

negro  race,  493. 
Thomson,  A.,  on  adhesions  between  fetus 

and  membranes,  454. 
Thorn,  on  atrophy  of  uterus  and  ovaries 
after     all     exhausting     diseases, 
146. 
Thorndyke,  on  frequency  of  splanchnop- 
tosis, 602. 
Thrombosis,   danger  of,   in   anemia  from 
fibroid  tumors,  504. 
'.  Thrush,  a  cause  of  pruritus,  296,  298. 


692 


IISTDES. 


Thyroid    gland,     changes    in,     associated 
with    functional    neuroses,     568, 
575. 
with  obesity  and  sterility,  367. 
extract  of,  in  treatment  of  adiposis  do- 
lorosis,  249. 
of  dysmenorrhea,  117. 
of  fibroid  tumor,   508. 
of  inoperable  cancer,  539. 
of  intermenstrual  pain,  136. 
of  obesity,  248. 

of  symptoms  at  menopause,  89. 
Tilt,   on   functional   amenorrhea,   149. 

on  the  menopause,  89,  90,  91. 
Tobacco,     excessive     use     of,     headache 
caused  by,  227. 
injurious  in  syphilis,  422,  441. 
Tobler,  Marie,  on  constancy  of  menstrual 

molimina,  106. 
Toilet  accommodations,  defective,  associ- 
ciated  with  constipation,  59,  212. 
with  immorality,  212. 
Tongue,   epithelioma   of,   associated   with 
excessive  use  of  tobacco,  422,  441. 
diagnosis    between    syphilis    of,    and 
epithelioma,  422. 
Tonsils,  chancre  of,  401,  404. 

hypertrophy  of,    associated  with,  defec- 
tive physical  development,  57. 
associated  with  disturbances  of  men- 
struation,  57. 
Toothache,  association  of,  with  menstrua- 
tion, 106. 
Torrey,  J.   C,   on  antigonococcus  serum, 

379. 
Torsions  of  uterus.     See  Uterus. 
Teuton,     on     gonococcus     in     squamous 

epithelium,  378. 
Toxemia,  headache  from,  226. 
Trachea,   syphilis  of,  424. 
Trauma,  effects  of,   on  severity  of  syph- 
ilis, 396. 
in  causation  of  abortion,  455. 
of  appendicitis  in  child,  595. 
of  cervical  cancer,  516. 
of  coccygodynia,  261. 
of  functional  neuroses,  568. 
of  movable  kidney,  608. 
Treponema    pallidum.       See     Spiroclieta 
pallida. 


Trichiasis  of  vulva  a  cause  of  pruritus, 

301. 
Trigonum,  hyperemia  of,   distinction  be- 
tween, and  cystitis,  543. 
Trimanual  examination,  13. 
Trional  for  relief  of  insomnia,  242,  243, 
581. 
of  renal  colic,  619. 
Trivalve  speculum.     See  Speculmn. 
Troitski,  on  metastases  to  ovaries  during 

parotitis,  272. 
Trypsin  in  treatment  of  inoperable  can- 
cer, 539. 
Tuberculosis,  abortion  in,  455. 
amenorrhea  in,  148,  153,  159. 
beginning    apical,    a    cause    of   neuras- 
thenia, 568. 
effect  of,  on  severity  of  syphilis,  396. 
latent,  developing  during  post-operative 

convalescence,  634. 
of  bladder,  545. 
of    kidney,    545,    548,    549,    554,    557, 

558. 
pruritus  from,  260. 
sterility  from,  366. 
syphilis  in  etiology  of,  397. 
Tuberculosis  of  endometrium  a  cause  of 

uterine  hemorrhage,  176. 
Tuke,'H.,  on  psychasthenia,  569. 
Tumors,    abdominal,    constipation   caused 
by,  213. 
gauze  records  of,  17. 
splanchnoptosis    caused    by    removal 
of,  599,  602. 
brain,  headache  caused  by,  226. 

neurasthenia  caused  by,  568. 
fibroid.     See  Fibroid, 
ovarian,    appendicitis    associated    with, 
588,  590. 
bimanual  examination  of,  15. 
gauze  record  of,  18. 
in  child,  26. 
rectum  choked  by,   33. 
pelvic,  cancer  of  rectum  mistaken  for, 
34. 
constipation  from,  213,  222. 
backache  caused  by,  251. 
Turkish  bath  in  treatment  of  dysmenor- 
rhea,  116. 
Turpentine  enemata,  222. 


INDEX. 


693 


Typhoid  fever,  abortion  in,  455. 
abscess  of  ovary  in,  269. 
atresia     of     genital     tract     following, 

266. 
backache  caused  by,  256. 
headache    caused   by,    226. 
inflammation  of  ovaries  in,  269. 
of  uterine  appendages  in,  269. 
of  uterus  in,  269. 

Ulcer,  epitheliomatous,  of  face,  419. 
gastric,  simulation  of,  by  movable  kid- 
ney, 611,  612. 
varicose,  mistaken  for  ulcerative  gum- 
mata,  420. 
Ulcerations,     tubercular,     mistaken     for 
syphilis    of    oro-pharyngeal    cav- 
ity, 422. 
of  uterus  (so-called),  21. 
of  vagina,  334. 
Ulcerations  of  cervix.    See  Cervix. 
Unger,  on  isolation  of  gonococcus  in  the 

blood  current,  378. 
United  States,  age  of  first  menstruation 

in,  82. 
Uremic  poisoning.     See  Nephritis. 
Ureters,   catheterization   of,  for  purposes 
of  diagnosis,  29,  548,  617. 
compression  of,  by  fibroid  tumors,  503, 

505. 
palpation  of,  by  vagina,  13. 
secondary  infection  of,  by  gonococcus, 

376. 
thickening  of,  in  tuberculosis  of  kidney, 
13. 
Urethra,  caruncle  of,  306. 
chancre   of,   400. 
gonococcus     infection     of,     306,     359, 

376. 
stricture  of,  360. 
syphilis   of,   425. 

treatment   of   gonococcus   infection   of, 
387. 
Urethral  dilators   in   mechanical   evacua- 
tion of  uterus,  469. 
Urethral  glands.     See  Skene's  glands. 
Urethritis,  gonorrheal,  260,  387. 
Urination,  frequency  of,  in  cystitis,   547, 
549,  553. 
in   functional    neuroses,  565,  668. 


Urination,    frequency    of,     retrodisplace- 
ments  of  uterus,  322. 
frequent  and  painful,  in  gonorrheal  in- 
fection of  genitalia,  385. 
increase  in  amount   of,   during  Dietl's 
crises,  411,  413. 
Urine,  albumen  in,  in  cystitis,  549. 
in  pyelitis,  548,  549. 
blood  in,   during   a  Dietl's   crisis,   611, 

613: 
blood  pigment  in,  during  chlorosis,  158. 
preservation   of,   for   examination,    548, 

561. 
pus  in,  during  cystitis,  548,  549,  554. 
removal  of,  from  bladder  with  suction 

apparatus,  553. 
routine    examination    of,    by   gynecolo- 
gist, 6. 
sugar  in,  a  cause  of  pruritus,  296,  297. 
Urotropin  in  prevention  of  cystitis,  557, 

558. 
Uterine'  tubes,   abscess  of,   accompanying 
septic  abortion,  471. 
chronic  disease  of,  mistaken  for  proc- 
titis, 34. 
closure  of,  from  infection,  275,  335,  365, 

376. 
gonococcus  infection  of,  376,  378,  381. 
inflammatory  disease  of,  involving  the 

rectum,  33. 
maldevelopment  and  disease  of,  a  cause 

of  sterility,  365,   374. 
syphilis  of,  427. 
"  Uterine  stones,"  495. 
Utero-sacral  ligaments,    shortening  of,   a 

cause  of  abortion,  456. 
Uterus,  abnormal  positions  of,  318. 

affections  of  neck  of,  cause  of  sterility, 

361. 
anteflexion  of,  cause  of  sterility,  363. 
congenital  nature  of,  318. 
risks  of  dilatation  in,  125. 
ascensus  of,   318. 
atrophy   of,    after   exhausting   diseases, 

148,   190,   366. 
backache  in  disease  of,  251. 
bimanual  examination  of,  11. 
carcinoma  of.     See  Cancer, 
changes  in,  after  the  menopause,  90. 
during  menstruation,  81. 


694 


INDEX. 


Uterus,  danger  of  applications  to  interior 
of,  294,  509. 
curettage   of,   for   diagnosis   of   cancer,- 
170,  525,  527. 
for  hemorrhage,  189,  510. 
for  inoperable  cancer,  534. 
for  remnants  of  abortion,  190,  467. 
for  sterility,  373. 
method    of,    189. 
disease  of,  mistaken  for  disease  of  the 

rectum,  33. 
displacements    of,    317. 
gonococcus  in  muscular  coat  of,  378. 
infantile,  cause  of  amenorrhea,  150. 

cause  of  sterility,  363. 
inflammation  of,  due  to  infectious  dis- 
ease, 269. 
inversion   of,   a   cause   of  menorrhagia, 
173. 
mistaken  for  submucous  fibroid,  502. 
involution  of,  imperfect  after  abortion,, 

470. 
manual  reposition  of,  326,  462. 
massage  of,  in  incomplete  abortion,  467. 
mechanical  evacuation   of   contents   of, 
in  abortion,  indications  for,  464. 
instruments  needed  for,  469. 
method  of  procedure  in,  467. 
mobility  of,  an  indication  for  operation 

in  cancer,  532. 
mobility  of,  on  bimanual  examination, 

12. 
normal  position  of,  11,  317,  320. 
packing  with  gauze  for  displacement  of, 

323. 
packing  with  gauze  for  hemorrhage  of, 

187,  469. 
prolapse  of,  abortion  due  to,  456. 
age  when  most  frequent,  322. 
cystitis  associated  with,  322,  334. 
etiology  of,  321. 
treatment  of,  333. 
retrodisplacements   of,   353. 
backache  due  to,  251,  256. 
congenital,  320. 
constipation  due  to,   33,   322. 
diagnosis  of,  322. 
dysm.enorrhea    associated    with,    110, 

320. 
importance  of,  319. 


Uterus,  retrodisplacements  of,  indications 
for  treatment  of,  320. 
manual  reduction  of,  326. 
membranous  dysmenorrhea  associated 

with,  129. 
neurasthenia  from,  320. 
operative  treatment  for,  332. 
pessaries  in  reduction  of,  324. 
relaxed     vaginal     outlet     associated 

with,  320. 
short  vagina  a  cause  of,  320. 
splanchnoptosis  a  cause  of,  600. 
statistics  of  frequency  of,  319. 
sterility  caused  by,  363,  372. 
symptoms  of,  322. 
varieties  of,  320. 
rupture  of,  in  fibroid  tumors,  505. 
subinvolution    of,    a    cause    of    hemor- 
rhage, 172. 
superinvolution  of,  a  cause  of  amenor- 
rhea, 160. 
suspension    of,   for    retrodisplacements, 

332. 
syphilis  of,  427. 
torsion  of,  319. 
"  ulcerations  of,"  21. 
vaginitis  following  removal  of,  282. 

Vagina,   absence  of,   a  cause  of  sterility, 
372. 
atresia  of,  congenital,  142,  267. 
difficult  labor  a  cause  of,  145,  260. 
in  infants,  144. 
infectious   diseases   a   cause  of,   142, 

145,  265,  360. 
pessaries  a  cause  of,  145. 
sterility  resulting  from,  360. 
trauma  a  cause  of,  146. 
chancre  on  walls  of,  400. 
deformities    of,    a    cause    of    sterility, 

360. 
drainage  by,  in  cystitis,  562. 
examination  by,  in  constipation,  215. 
gonococcus  infection  of,  376. 
gonorrheal  inflammation  of,  a  cause  of 

sterility,  376. 
inspection  of,  19. 

measiirement  of,  to  fit  a  pessary,  326. 
painting  vault  of,  31. 
palpation  by,  10. 


INDEX. 


695 


Vagina,    septate,    dangers    of   conception 
with,  360. 
shortness  of,  a  cause  of  retrodisplace- 
ment  of  uterus,  320. 
a  cause  of  sterility,  360. 
stricture  of,  a  cause  of  sterility,  360. 
Vaginal    discharge,    acidity    of,    fatal    to 
gonococcus,  379,   384. 
at  menopause,  100. 
difference  between,  and  cervical,  20. 
early  syraptom  of  cancer,  169,  518,  519, 

520. 
first  symptom  of  gonococcus  infection, 

385. 
in  gynecological  examination,  20. 
in  vaginitis.     See  Vaginitis, 
masturbation  due  to,  310. 
peculiarities  of,  in  gonorrhea,  380. 
pruritus  due  to,  296,  298,  303. 
with  fibroid  tumor,  498. 
Vaginal   douches,    disinfecting,    in   diph- 
theritic vaginitis,  281. 
in  inoperable  cancer,  542. 
in  vaginitis,  284. 
in  vulvitis,  276. 
with  pessaries,  331. 
hot,  in  cystitis,  510. 

in  hemorrhage  from  uterus,  186,  608. 
in  pelvic  affections  in  general,  31. 
in  pelvic  inflammation,  342. 
in  pruritus,  299. 
in  vaginitis,   283. 
sedative,  in  cancer,  541. 
Vaginal  examination,  of  pelvic  organs,  10. 
restriction   of,   in  threatened   abortion, 
463. 
Vaginal  outlet,  relaxation  of,  constipation 
associated  with,  215. 
contraindication    to    use    of   pessary, 

327. 
defecation  interfered  with  by,  222. 
insomnia  caused  by,  239. 
recognition  of,  on  examination,  10. 
retroflexion  associated  with,  320. 
sterility  associated  with,  360. 
Vaginismus,  definition  of,  304. 
etiology  of,  304. 

galvanic  current  in  treatment  of,  307. 
gonococcus  infection  a  cause  of,  305. 
prognosis  of,  306. 


Vaginismus,    rest    in    the    treatment    of, 
306. 
sterility  from,  306,  357,  368,  372. 
suffering  from,  304. 
surgical  treatment  of,  308. 
urethral  form  of,  306. 
Vaginitis,    280. 

age  when  most  frequent,  280. 

applications  for  relief  of,  284. 

diphtheritic,   281. 

douches  for,  283. 

emphysematous,  281. 

etiology   of,   282. 

exfoliative,  281. 

gonorrheal,  280. 

membranous   dysmenorrhea  caused  by, 

129. 
office  treatment   of,  284. 
of  pregnancy,  281. 
packs  for  relief  of,  285. 
post-operative,  282. 
pruritus  caused  by,  393. 
pufi-box  treatment  of,  285. 
senile,  282. 

treatment  of,  in  general,  282. 
varieties  of,  280. 
yeast  treatment  of,  285. 
Valerian   in   treatment   of   masturbation, 
316. 
in    treatment    of    threatened    abortion, 
458. 
Varicella,  diagnosis  between,  and  variola 

form  of  pustular  syphilide,  417. 
Variola,    diagnosis   between,    and   variola 

form  of  pustular  syphilide,  417. 
Vaso-motor    disturbances,    headache    due 

to,  225. 
Vaso-motor  exhaustion  a  cause  of  insom- 
nia, 238. 
Vaso-motor  neurosis,  explanation  of  mi- 
graine as,  228. 
Vaughan,  Ethel,  on  rest  in  treatment  of 

excessive  menstruation,  183. 
Vedeler,  on  dysmenorrhea  associated  with 

an  anteflexed  uterus,  107. 
Veit,  description  of  gonococcus  by,  377. 
on  atresia  of  vagina  from  application 

of  chloride  of  zinc,   146. 
on   atrophy    of    uterus    in    acromegaly, 
148. 


696 


INDEX. 


Veit,  ou  diabetes  in  the  causation  of  pru- 
ritus, 296. 
on  local  changes  in  pruritus,  297. 
on  masturbation  as  a  cause  of  vaginis- 
mus, 368. 
on  sexual  irritation  as  a  cause  of  fibroid 

tumors,  494. 
on   surgical    treatment    of    vaginismus, 

308. 
on   uterine   changes   during   menstrua- 
tion, 81. 
Veronal  in  treatment  of  functional  neu- 
roses,  581. 
in  treatment  of  insomnia,  243. 
Vesical  tuberculosis,  545. 
Vesiculitis,  chronic,  a  cause  of  male  ster- 
ility, 352. 
Viburnum  prunifolium,'  in  treatment  of 

uterine  hemorrhage,  185,  462. 
Vicarious   menstruation.     See   Menstrua- 
tion. 
Vineberg,  on  amenorrhea  associated  with 

prolonged  lactation,  145. 
Virchow,  on  chlorosis,  147,  155. 

on  displacement  of  the  intestines,  597. 
Virginia,   Hot    Springs   of,   treatment   of 

obesity  at,  246. 
Viscera,  abdominal,  displacement  of.     See 

Splanchnoptosis. 
Virgins,  examination  of  pelvic  organs  in, 
duty  of  physician  as  to,  112,  150, 
181,   323. 
method   of,    27,   383. 
Vomiting,  pernicious,  a  reason  for  artifi- 
cial abortion,  474. 
treatment  of,  in  chlorosis,  158. 
Vulva,    atresia    of,    caused   by   infectious 
disease,  146,  265. 
gonococcus  infection  of,  376. 
infantile  character  of,   associated  with 
maldevelopment  of  genital  tract, 
358. 
inspection  of,  in  gynecological  examina- 
tion, 19. 
syphilis   of,   426. 

trichiasis     of,     a     cause     of     pruritus, 
301. 
Vulvitis,  age  when  most  frequent,  275. 
gonococcus,  infection  in,  276. 
in  child,  276.  [ 


Vulvitis,  localization  of,  276. 

masturbation  associated  with,  310. 

nature  of,  275. 

rarity  of,   275. 

symptoms  of,  276. 

treatment  of,  276. 

vaginitis  associated  with,  280. 
Vulvo-vaginal    glands.       See    Bartholin's 

glands. 
Vulvo-vaginitis     in      little      girls,      ages 
when  it  is  seen  most  frequently, 
383. 

complications  of,  391. 

importance  of,  381. 

methods  of  contracting,  382. 

sequelae  of,  384. 

symptoms   of,   381. 

treatment  of,  389. 

Waiting   room,   1. 

Walker- Gordon  milk,  45. 

Walther,  on  quinine  as  a  contractor  of  the 
uterine  fibres,  469. 

Wassermann,    production    of    gonococcus 
by,  379. 

Water,  drinking,  abundance  of,  in  consti- 
pation, 218,  223. 
necessity  for  purity  in  public  supply  of, 

44. 
reduction  of,   in  treatment  of  obesity, 
247. 

Water-closet,   suitable  height   of  seat  in, 
210. 

Weber,     on    membranous     dysmenorrhea, 
128. 

Webster,  on  case  of  vicarious  menstrua- 
tion requiring  radical  treatment, 
162. 
on  fibrosis   of  external  genitals  as  the 

cause  of  pruritus,  296. 
on  interval  between  the  menstrual  pe- 
riods, 86. 

Weeping,  continual,  a  cause  of  constant 
headache,  228. 

Weight,  at  birth,  affected  by  gonococcus 
infection  in  mother,  378. 
excessive.     See  Obesity, 
increase  of,  in  girls,  65. 

Weir,  W.  H.,  on  cervical  cancer  in  nulli- 
parae, 517. 


INDEX. 


697 


Welt-Kakels,   Sara,   on  gonorrheal  vulvo- 
vaginitis in  little  girls,  363,  381, 
382,  383. 
Wertheim,  on  cancer,  96,  530. 

on  gonocoecus  in  blood-vessels  and  se- 
rosa of  peritoneum,  378. 
on  gonocoecus   in   substance   of   ovary, 

378. 
on    gonorrheal    infection    a    cause    of 

sterility,  351. 
on  re-infection  in  gonorrhea,  380. 
West,  on  proportional  frequency  of  fibroid 
tumors  in  married  women,  494. 
on  zinc   ointment  in  the  treatment  of 
pruritus,  301. 
Whey,  in  treatment  of  constipation,  223. 
Whiskey,    danger    of,    in    dysmenorrhea, 
114. 
in  insomnia,  239. 
von    Wild,    on    galvano-faradism    in    the 
treatment  of  constipation,  219. 
on  gymnastics  in  the  treatment  of  con- 
stipation, 218. 
Wilks,  on  vicarious  menstruation,  160. 
Williams,  J,  W.,  on  fibroids  in  the  negro 
race,  493. 
on  use  of  the  obstetric  forceps,  483. 
Williams,  R.,  on  heredity  in  causation  of 

cancer,  515. 
von  Winckel,  on  emphysematous  vagini- 
tis, 281. 
on  myomata  and  sterility,  364. 
Winter,  G.,  on  association  betv^een  fibroid 
tumors  and  heart  disease,  505. 
on  prophylaxis  of  cancer  through  edu- 
cation of  the  public,  530. 
on  sarcomatous  degeneration  of  fibroid 
tumors,  496. 
Withrow,  on  vicarious  menstruation,  160, 

161. 
Witthauer,  on  styptol  in  treatment  of  ute- 
rine hemorrhage,  185. 
Wood,  H.  C,  on  impurity  of  the  prepa- 
rations of  cannabis  indica,  234. 


Worms,    intestinal,    and    appendicitis    in 
child,  595. 
rectal,  a  cause  of  masturbation,  310. 
a  cause  of  pruritus,  33,  298. 
Wuth,   case  of   imperforate  hymen  prob- 
ably caused  by  measles,  258. 
Wyder,    on    membranous    dysmenorrhea, 
128. 

X-ray  in  diagnosis  betvpeen  renal  calculus 
and  movable  kidney,  616. 
in  diagnosis  of  enteroptosis,  601. 
of  gastroptosis,  601. 
of  osteo-arthritis,  574. 
of  redundant  sigmoid,  213. 
in  treatment  of  pruritus,  302. 
of   uterine   cancer,   537. 
Xeroform  in  treatment  of  chancre,  404. 

Yeast,    brewer's,    in    treatment    of    gono- 
coecus infection,  388. 

in  treatment  of  pruritus,  298. 

in  treatment  of  vaginitis,  286. 
Yeast,  fungus,  in  pruritus,  298. 

Zinc,  chloride  of,  atresia  of  vagina  follow- 
ing the  therapeutic  use  of,  146. 
in  cauterization  of  vagina  for  gonor- 
rheal infection,  374. 
in  treatment  of  chancre,  404. 
oxide  of,  as  lotion  in  treatment  of  pru- 
ritus, 300. 
as  ointment   in  treatment  of  gonor- 
rheal infection  in  a  child,  391. 
as  powder,  in  treatment  of  chancre, 

404. 
in  syphilitic  lesions,  442. 
in  syphilitic  lesions  in  child,  443. 
valerianate  of,  in  prophylaxis  of  abor- 
tion, 462. 
Zweifel,  on  case  of  atresia  of  genital  tract 
following  typhoid  fever,  472. 
on   frequency   of  gonorrheal   infection, 
376. 


(6) 


THE    END. 


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